Problem: What would a nurses note need to consist of with this clients information.
Angela Stevens is a 28-year-old woman on postoperative day (POD) #2 after small bowel resection and lysis of adhesions. She has had two previous surgeries for chronic abdominal pain due to severe Crohn's Disease and has developed narcotic tolerance and dependence. She has been clinically stable post-op but has been c/o increasing incisional pain despite the Fentanyl/Ropivacaine epidural drip being increased from 8 ml/hr to 12 mL/hr earlier today. She has hydromorphone (Dilaudid) Img IV push PRN every 3 hours for abdominal pain that remains persistently greater than 6/10 on a 0-10 pain scale. Her pain goal is to be four or less.