write a fictitious or make-believe case study paper, you must carefully address a number of sections in a specific order with specific information contained in each. The guideline below outlines each of those sections.
Section
Information to Include
Introduction (patient and problem)
Explain who the patient is (Age, gender, etc.)
Explain what the problem is (What was he/she diagnosed with, or what happened?)
Introduce your main argument (What should you as a nurse focus on or do?)
Pathophysiology
Explain the disease (What are the symptoms? What causes it?)
History
Explain what health problems the patient has (Has she/he been diagnosed with other diseases?)
Detail any and all previous treatments (Has she/he had any prior surgeries or is he/she on medication?)
Nursing Physical Assessment
List all the patients health stats in sentences with specific numbers/levels (Blood pressure, bowel sounds, ambulation, etc.)
Related Treatments
Explain what treatments the patient is receiving because of his/her disease
Nursing Diagnosis & Patient Goal
Explain what your nursing diagnosis is (What is the main problem for this patient? What need to be addressed?)
Explain what your goal is for helping the patient recover (What do you want to change for the patient?)
Nursing Interventions
Explain how you will accomplish your nursing goals, and support this with citations (Reference the literature)
Evaluation
Explain how effective the nursing intervention was (What happened after your nursing intervention? Did the patient get better?)
Recommendations
Explain what the patient or nurse should do in the future to continue recovery/improvement
Full Answer Section
Pathophysiology
Postoperative pain is a common complication following major surgery, like knee replacement. It arises from inflammation and tissue injury at the surgical site. Symptoms include sharp, throbbing pain, swelling, and stiffness in the affected joint.
History
Mr. Jones has a history of hypertension, controlled with medication. He is allergic to penicillin. He denies any history of prior surgeries.
Nursing Physical Assessment
- Vital Signs: Blood pressure 140/80 mmHg, heart rate 92 bpm, temperature 98.6°F, respiratory rate 16 breaths/minute.
- Pain Assessment: Mr. Jones reports a pain level of 7 out of 10 on a numeric pain scale, localized to the incision site. The pain is described as throbbing and worse with movement.
- Bowel Sounds: Active in all four quadrants.
- Ambulation: Mr. Jones is able to ambulate with assistance using a walker, but reports pain and difficulty bearing weight on the affected knee.
Related Treatments
Mr. Jones is currently receiving intravenous (IV) pain medication around the clock, but this is not providing adequate pain relief.
Nursing Diagnosis & Patient Goal
- Nursing Diagnosis: Acute Pain related to surgical incision as evidenced by patient report and pain scale score.
- Patient Goal: Reduce Mr. Jones' pain level to a manageable level (4 out of 10 or less) within 24 hours to facilitate participation in physical therapy and improve overall recovery.
Nursing Interventions
- Pain Reassessment: Regularly assess Mr. Jones' pain level using a numeric pain scale and document the location, intensity, and quality of pain (McCaffery & Beebe, 2013).
- Medication Management: Collaborate with the physician to administer pain medication according to the pain assessment and established protocols (McCaffery & Beebe, 2013). This may involve transitioning from IV pain medication to oral medication as tolerated.
- Non-pharmacological Interventions:
- Apply ice packs to the incision site for 20-minute intervals to reduce inflammation and pain (McCaffery & Beebe, 2013).
- Encourage relaxation techniques such as deep breathing and guided imagery to promote pain relief and coping (Chiang et al., 2019).
- Provide diversional activities such as listening to music or watching television to distract Mr. Jones from focusing on the pain (McCaffery & Beebe, 2013).
- Patient Education: Educate Mr. Jones about the importance of pain management and the different pain management options available (McCaffery & Beebe, 2013). Instruct him on how to use the pain scale effectively and report any breakthrough pain promptly.
Evaluation
Following implementation of these interventions, Mr. Jones' pain level decreased to a 4 out of 10 within 12 hours. He reported improved sleep and was able to participate in physical therapy with minimal discomfort.
Recommendations
Mr. Jones should continue to use the pain scale to communicate his pain level effectively. He should continue with the non-pharmacological interventions listed above and report any worsening pain to the nurse. The nurse should continue to monitor Mr. Jones' pain level and adjust the pain management plan as needed in collaboration with the physician.
Citations
- McCaffery, M., & Beebe, A. (2013). Pain: Pathophysiology and assessment (6th ed.). Mosby Elsevier.
- Chiang, H.-Y., Chen, M.-C., & Yeh, M.-L. (2019). The effects of guided imagery on pain and anxiety in adult patients with postoperative pain: A systematic review and meta-analysis. Journal of Clinical Nursing, 28(17-18), 3392-3404.