Question

Mr. J.S. is a 66-year-old man who just arrived on the medical surgical unit following an appendectomy. He is complaining of pain. You are the nurse assigned to care for Mr. J.S.

1. What critical assessment data do you need to identify and collect?

2. Formulate a nursing diagnosis based on your assessment data.

3. Describe two nursing interventions to assist the patient.

4. What criteria would you use to evaluate the effectiveness of the nursing interventions?

Answer 1

1.The nurse has to inquire about the pain that the patient is experiencing. Asking where exactly the pain is gives the location of the pain. Asking if the patient has turned or moved helps the nurse to establish mobility status as well as severity of pain. Asking the patient to rate the pain on a scale of 0-10 helps to assess severity of pain.

2.Acute pain related to presence of surgical incision as manifested by facial grimacing.

3 Nursing interventions are

.Note clients age /developmental level and condition affecting ability to report pain parameters.

Note location of the surgicsl procedure and assess for referred pain.

4.Evaluation is the step of the nursing process that allows nurses to determine whether nursing interventions are successful in improving a clients condition or well being. By comparing the clients actual responses to nursing intervention with expected outcomes established during planning, you determine if goals of care are met.

In this situation Subjective data is supposed a pain scale of 7/10.Objective data include dressing on surgical site, facial grimacing.

The Expected outcomes are that at the end of the shift the client will report pain is relieved and controlled by verbslizing that his pain scale from 7/10 becomes 2/10 after taking medications.