Case study - Acute pain: Nursing

Nurse Nadia works on an orthopedic unit and is caring for Brian, a 51-year-old male with a history of degenerative joint disease, who was recently admitted for intractable back pain. After settling Brian in his room, Nurse Nadia goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Brian’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Nadia recognizes important cues, including Brian’s vital signs, which are blood pressure 172/92 mmHg, heart rate 102 per minute, and respirations 22 per minute. She also notices Brian is gripping the side rails and clenching his jaw. When asked about his pain, he reports a current pain level of 9 out of 10, and that his tolerable level of pain is 5 out of 10.

Next, Nurse Nadia analyzes these cues. She reviews the electronic health record, or EHR, and notes that Brian is prescribed 0.5 mg of IV hydromorphone every three hours PRN, and he received his last dose in the emergency department one hour ago. Nurse Nadia realizes Brian needs effective pain management.

Now, using the information she has gathered, along with Brian’s medical history, Nurse Nadia chooses a priority hypothesis of acute pain.

Then, she generates solutions to address Brian’s pain that will include pharmacologic and nonpharmacologic pain management interventions; and she establishes the expected outcome that after intervening, Brian will report a pain level of 5 or less out of 10 within two hours.

Nurse Nadia then takes action to implement these solutions. She knows that since Brian’s most recent dose of pain medication was one hour ago, he can't receive his next dose for two more hours. Since Brian is in severe pain, she verifies that Brian isn’t allergic to any medications and then calls the provider, reporting Brian’s current pain assessment and vital signs. The provider prescribes a one-time dose of IV ketorolac 30 mg now.

While waiting for the pharmacist to approve this new medication order, Nurse Nadia dims the lights in Brian’s room, plays relaxing music from the television, and applies a cold pack to his lower back. Then, she delegates to the assistive personnel to help elevate Brian’s legs on pillows.

Once the pharmacist approves the ketorolac medication order, Nurse Nadia prepares the dose and re-enters Brian’s room.

Nurse Nadia: The health care provider prescribed a dose of ketorolac for your pain.

Brian: I’ve never taken ketorolac, what is it?

Nurse Nadia: It’s an anti-inflammatory pain medication, like ibuprofen, but instead of a pill, it can be given through your IV.