Video Case Study - Nursing Care for Acute Pain

Nurse Nadia works on an orthopedic unit and is caring for Brian, a 51-year-old with a history of degenerative joint disease, who was admitted for intractable back pain.

In collaboration withthe registered nurse, RN Katie, 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 temperature 98.8 F or 38.9 C, heart rate 99 beats per minute, respirations 21 breaths per minute, and blood pressure 152/82 mmHg.

She also notices Brian is slightly diaphoretic and grimacing. When asked about his pain, he reports a current pain level of 6 out of 10, and that his tolerable level of pain is 3 out of 10.Next, Nurse Nadia analyzes these cues.

She reviews the electronic health record, or EHR, and notes that Brian is prescribed IV ketorolac every six hours PRN, and he received his last dose two hours ago.

Nurse Nadia compares her findings to Brian’s assessment conducted by RN Katie and realizes Brian needs effective pain management.Now, using the information she has gathered, along with Brian’s medical history, Nurse Nadia reports her findings to RN Katie who chooses a priority hypothesis of acute pain.Then, Nurse Nadia collaborates with RN Katie to generate solutions to address Brian’s pain that will include pharmacologic and nonpharmacologic interventions; and they establish the expected outcome that after intervening, Brian will report a pain level of 3 or less out of 10 within one hour.

Nurse Nadia then takes action to implement these solutions. She knows that since Brian’s most recent dose of ketorolac was two hours ago, he can't receive his next dose for four more hours.

Since Brian is in moderate pain, she verifies that Brian isn’t allergic to any medications and then calls the health care provider, reporting Brian’s current pain assessment and vital signs.

The provider prescribes a one-time dose of oral tramadol.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.Once the pharmacist approves the order, Nurse Nadia gathers supplies and re-enters Brian’s room.Nurse Nadia: Hi Brian, the health care provider prescribed a dose of tramadol for your pain.Brian: I just had pain medicine through my IV, isn’t it too soon to take something else?Nurse Nadia: Earlier you were given a medication called ketorolac.

Since you aren’t due for another dose of that yet, the provider prescribed tramadol in the meantime. It’s safe to take along with the medication you received earlier.Brian nods his head and agrees to take the medication.

Nurse Nadia then proceeds to administer the tramadol using the principles of safe medication administration. She informs Brian that she’ll allow him to rest for a while and places his call light at the bedside.One hour later, Nurse Nadia enters the room to evaluate the outcome of her actions.

She takes Brian’s vital signs and asks about his pain. His temperature is 98.4 F or 38.7 C, heart rate is 88 beats per minute, respirations are 18 breaths per minute, blood pressure is 121/83 mmHg, and his pain is 4 out of 10.Brian appears more comfortable and is no longer grimacing or sweating.Although Brian’s vital signs have returned to normal, he’s still reporting moderate pain.

Nurse Nadia recognizes the expected outcome of a pain rating of 3 or less out of 10 hasn’t been met, so she asks Brian what she can do to address his pain more thoroughly.Brian: I feel better, but I’m still uncomfortable.

The ice, music, and medicine really seemed to help, but I keep waking up from the noises in the hallway and people coming in and out of my room.Nurse Nadia documents Brian’s response to the pharmacologic and nonpharmacologic pain interventions and notes that the noise disruptions in the hallway impaired Brian’s comfort and relaxation.Then, she discusses her findings with RN Katie, and they revise the plan of care to ensure Brian receives more rest.Next, Nurse Nadia freshens and reapplies Brian’s ice pack, provides him with ear plugs, and closes the door to his room.

She places a sign on the door that says, “Please see the nurse before entering.”Alright, as a quick recap…Nurse Nadia recognized and analyzed cues related to Brian’s intractable back pain and in collaboration with the registered nurse, RN Katie, prioritized hypotheses and generated solutions to address this problem.Nurse Nadia and RN Katie then implemented pharmacologic and nonpharmacologic pain measures and evaluated Brian’s outcomes and compared them to the expected outcome.

Since Brian’s pain remained 4 out of 10 following interventions, they revised the plan of care to minimize noise and disruptions to promote Brian’s rest