What is Tanners Clinical Judgement Model?
NIRR
Noticing, Interpreting, Reflecting, Responding
What is pain?
Whatever the patient says it is!
Complex and individualized
What are the three categories of pain medications
Non-opioid
Opioid
Co-analgesic
What is the Nursing Process?
ADPIE
Assessment, diagnosis, planning, implementation, evaluation
What does clinical judgement require?
Flexible ability to recognize salient aspects of an undefined clinical situation, interpret their meanings, and respond appropriately
Understanding the situations
Understanding of illness experience for both patient and family
Physical, social, and emotional strengths
Coping resources
Differences between acute and chronic pain
Acute Pain
Sudden onset
Less than 3 months time for normal healing to occur (can turn into chronic pain)
Mild to severe
Generally a precipitating event or illness can be identified
Manifestations reflect sympathetic nervous system activation:
Increased heart rate
Increased respiratory rate
Increased blood pressure
Postoperative pain, labor pain, sudden trauma, some infections.
Treatment of the underlying cause; goal is pain control with eventual elimination
Chronic Pain
Gradual or sudden onset
Over 3 months duration; may start acute but continues past normal recovery time
Cause may be unknown
Does not go away; characterized by period of waxing and waning
Behavior manifestations
Decreased physical movement/ activity
Fatigue
Withdraw from others and social interaction
Can be disabling and accompanied by anxiety and depression
Treatment goals
Focus on enhancing function and quality of life; this is how we measure intensity for chronic pain.
Examples and Benefits to Nonopioid medications
Acetaminophen, NSAIDs (Ibuprofen, naproxen, celecoxib), aspirin.
Do not produce addition, but can cause other problems with organs.
Can be used with opioids to lower doses.
Why do we use the nursing process?
We need some autonomy, we are the ones with the patient for a long time. It gives us a structure to follow
What are some things that make clinical judgement complicated?
Number of patients, Families, Collaborative care team, coordination of admissions and discharges, time management, delegation, experinces, etc.
How do you treat breakthrough pain?
Have to give them equivalent medication because the patient is worse. Can not really ‘cap out’ on opioids. Do not give medications such as tylenol when they are used to morphine.
Preference route is PO, but the fastest route is IV route.
What is a ceiling effect? What drug class does NOT have it?
Taking higher doses does not increase the effect.
OPIOIDs do not have a ceiling effect = overdose
What is done in the implementation phase?
Carry out the plan of care
Nurse assumes responsibility
Goals are used as a focus
Ongoing assessment
Make revisions when necessary
All interventions should be patient focused and outcomes directed
Delegations: right circumstances, tasks, and person
Communication needs to be clear: maybe have them repeat it back to you to make sure it is correct
What is the most important thing to do when NOTICING data/ a situation?
ALWAYS look at the patient first, do not rely on the monitors. Monitors can help, but you have to look at what is going on from the patient, collaborative care team, etc.
How do you measure intensity for chronic pain?
Focus on enhancing function and quality of life; this is how we measure intensity for chronic pain.
Constipation (most common)
Nausea/ vomiting
Sedation
Respiratory depression
Hypotension
Pruritus
An uncomfortable, irritating sensation that creates an urge to scratch that can involve any part of the body.
4. The registered nurse (RN) has been assigned her patients for the day-shift. After completing initial rounds and assessing the patients, for which patient would the RN need to go to first?
A. A patient exhibiting a fever, sweating profusely, and appearing restless.
B. A patient who recently underwent an appendectomy and has just been administered pain medication.
C. A patient scheduled for occupational therapy at 1300.
D. A patient scheduled for a routine check-up later in the day.
A. A patient exhibiting a fever, sweating profusely, and appearing restless.
Symptoms indicate that the patient may be experiencing an acute issue requiring immediate intervention. Fever, profuse sweating, and restlessness can be signs of infection, pain, or other serious conditions that need prompt assessment and management to prevent complications and ensure the patient's well-being.
Give me an example (in detail) using the steps of NIRR
Student answer
PCA Rules/ Education for Patient and Family
Patient presses a button to self administer analgesic agent at set time; ONLY the patient can hit the button
Educate patient
Relationship between pain, pushing button, pain relief, and only patient can push the button
Can still have side effects and can still lead to complications such as sedation
What are some gerontologic considerations with using pain medications?
Sensitive to agents that produce sedation and CNS effects
Initiate with low dose and titrate slowly
Increased risk for NSAID induced GI toxicity
Acetaminophen preferred for mild pain
Opioid dose should be reduced 25-50%
Musculoskeletal pain is the most common with this age; pain is not a normal part of aging. Patients will a lot of the time think that it is okay just because they are getting older.
Metabolize drugs slowly, increased risk of GI bleeding, drug interactions (polypharmacy), cognitive impairment
Upon identifying a nursing diagnosis of acute pain, the nurse establishes the following suitable patient-focused goal:
A. Educate the patient about non-pharmacological pain management techniques.
B. Provide pain relief medication 30 minutes prior to physical therapy sessions.
C. Ensure pain intensity is reported as 3 or lower throughout the hospital stay.
D. Evaluate the impact of pain intensity on patient functionality.
C. Ensure pain intensity is reported as 3 or lower throughout the hospital stay.
Suitable patient-focused goal, as it is specific, measurable, and time-bound. It addresses the nursing diagnosis of acute pain and outlines a clear objective (keeping pain intensity at a manageable level) that can be evaluated during the patient's hospital stay.