Assignment task:
Juan is Ms. Hayes's nurse. She puts her light on and asks for something for pain; she tells Juan that the abdominal pain she has is a 9. Juan brings her morphine 4 mg and gives her the IV push (IVP) dose. He comes back 15 minutes later to evaluate the effectiveness of the pain management plan.
Ms. Hayes is calm, smiling, and reports the pain at 0. Juan examines the abdominal dressing, the IV site, and listens to Ms. Hayes lungs. He notices the crackles in the lungs and is concerned. He observes that her respiration is shallow and rapid, and he asks her to breathe deeply and notices it triggers a cough; he also sees a pain response in her expression with the cough. He realizes that she has been under anesthesia for 3 hours and has been on an operating room table, a stretcher, or in her bed for the last 24 hours. And he also appreciates the effects of incisional pain on her respirations.
Ms. Hayes complains of dyspnea, feeling cold, and coughing up green phlegm. Her pulse oximetry is 87%, respiratory rate is 30; she breathes shallowly and is using accessory muscles to breathe. Her temperature is up to 102.9 F. You auscultate her lungs and find diminished breath sounds with crackles throughout that are present in the right lung, with a clear left lung in all fields. Her respiratory status has continued to decline despite the efforts you put in place to improve it, and she has a postoperative complication of pneumonia.
- Identify three pieces of assessment data (defining characteristics) that the nurse could use to support the actual nursing diagnosis of Acute Pain for Ms. Hayes
- List a minimum of three actual nursing diagnostic labels (not including Acute Pain) applicable to Ms. Hayes' current condition.
- Write two risk nursing diagnoses for Ms. Hayes.
- Write three nursing plans/goals for Ms. Hayes
- Three nursing interventions
- Evaluate
- Did goal met or not met?