NURS 6512N Week 4 – Health History, Tina Jones Shadow Health

Acute Pain Management in Nursing:
Managing acute pain is an immediate high priority, as it directly impacts a patient’s overall well-being and the effectiveness of other treatments.
Acute pain can limit a patient’s ability to participate in their own care, making it essential to address it promptly.
Effective acute pain management nursing interventions often include pharmacological treatments like analgesics as well as non-pharmacological approaches to reduce pain intensity.

Evidence-Based Nursing Interventions for Acute Pain

When addressing acute pain, it’s critical to consider evidence-based nursing practices. In the case of a patient like Tina, who reports significant pain in her foot, effective nursing interventions for pain relief might include prescribing analgesics and educating the patient about the use of medications. Additionally, nursing care for acute pain should involve non-pharmacological methods, such as rest, ice, compression, and elevation (RICE), which help reduce pain and inflammation without relying solely on medication.

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Non-Pharmacological Pain Management Techniques in Nursing

Incorporating non-pharmacological methods is a key component of comprehensive nursing care for acute pain. These interventions, such as relaxation techniques, guided imagery, and heat or cold therapy, can complement pharmacological treatments to provide more effective pain management. Nurses can also educate patients on using these methods to help control pain independently.

Managing Chronic Conditions: Diabetes and Asthma

Nursing Care Plan for Uncontrolled Type 2 Diabetes

For patients like Tina, with uncontrolled type 2 diabetes, a comprehensive nursing care plan is essential. The nursing care for type 2 diabetes should focus on controlling blood glucose levels, educating the patient about lifestyle changes, and monitoring for complications. Nurses should assess blood sugar regularly and intervene with appropriate medications and lifestyle modifications to prevent long-term complications.

Patient Education for Asthma Management

Although Tina reports that her asthma is well-controlled, patient education on asthma management is still necessary. Nurses should educate patients on recognizing asthma triggers and how to use rescue inhalers effectively. A key aspect of nursing interventions for asthma involves ensuring that the patient understands how to manage their asthma proactively to avoid severe episodes. This could include creating an asthma care plan to guide the patient in managing their condition.

Nursing Assessment for Asthma Patients

Routine nursing assessment for asthma patients is important to monitor lung function and identify any changes in symptoms. This includes auscultating lung sounds, assessing respiratory rate, and evaluating the use of medications. Nurses must educate patients on recognizing early signs of an asthma attack and seek medical intervention promptly.

Endocrine and Reproductive Health in Nursing

Assessing and Managing Oligomenorrhea in Nursing

Oligomenorrhea, characterized by irregular menstruation, can be a sign of underlying endocrine disorders. Nursing assessment for oligomenorrhea includes taking a detailed menstrual history and monitoring changes. Nurses may need to intervene by ordering lab tests, such as follicle-stimulating hormone (FSH) levels, to investigate potential causes like polycystic ovarian syndrome (PCOS) or thyroid imbalances.

Nursing Interventions for Polycystic Ovarian Syndrome (PCOS)

For patients diagnosed with PCOS, nursing interventions for polycystic ovarian syndrome include managing symptoms like irregular periods, excessive hair growth, and acne. Nurses should educate the patient on lifestyle changes, such as diet and exercise, and provide information about medical treatments to regulate hormones and improve fertility outcomes.

Managing Dysmenorrhea and Menorrhagia in Nursing

Dysmenorrhea (painful menstruation) and menorrhagia (heavy menstrual bleeding) are common reproductive health issues. Nursing care for dysmenorrhea and nursing care for menorrhagia includes pain management, hormonal therapies, and patient education on managing symptoms effectively. Nurses should assess the severity of these conditions and provide appropriate treatments such as nonsteroidal anti-inflammatory drugs (NSAIDs) or hormonal birth control.

Hypertension and Obesity in Nursing Practice

Nursing Diagnosis and Care Plan for Hypertension

Hypertension is a significant risk factor for many cardiovascular diseases. A nursing care plan for hypertension focuses on monitoring blood pressure regularly, educating the patient about lifestyle modifications (such as salt reduction, exercise, and weight management), and medication management to control hypertension effectively.

Obesity and Weight Management in Nursing Care

Obesity is a complex condition requiring multifaceted interventions. Nursing interventions for obesity and weight management should include assessing the patient’s dietary habits, encouraging physical activity, and offering resources for weight loss programs. Nurses should also provide patient education on the long-term health risks associated with obesity, such as diabetes and heart disease.

Nursing Interventions for Weight Reduction in Obesity

Effective nursing interventions for obesity and weight management often involve personalized plans that combine dietary counseling, exercise recommendations, and behavioral support. Nurses can play a critical role in guiding patients toward realistic and sustainable weight loss goals.

Managing Skin Infections and Subcutaneous Conditions in Nursing

Nursing Care for Local Skin and Subcutaneous Infections

For patients with local skin infections, such as those found in Tina’s case, nursing care for skin and subcutaneous tissue infection includes cleaning and dressing wounds, administering antibiotics, and monitoring for signs of systemic infection. Nurses must educate the patient on proper wound care and hygiene to prevent further infection.

Evidence-Based Nursing Interventions for Infections

Evidence-based interventions for treating skin infections may involve both pharmacological treatments (like topical or oral antibiotics) and non-pharmacological approaches (such as wound care protocols). Nurses should monitor for complications and educate the patient on how to care for their infection at home.General Nursing Interventions and Patient Education

Importance of Patient Education in Nursing Care

One of the most vital aspects of nursing care is patient education, especially in managing chronic conditions like diabetes, asthma, and hypertension. Educating patients empowers them to manage their health effectively and make informed decisions about their care.

Developing Effective Patient Care Plans

Nursing diagnosis and care plan example is a helpful tool in developing personalized care plans that address a patient’s specific needs. A well-structured care plan includes clear objectives, interventions, and expected outcomes tailored to the individual’s condition and health status.

Educating Patients on Self-Management for Chronic Diseases

Chronic conditions require continuous management. Patient education for managing chronic health conditions is an ongoing process. Nurses play an essential role in teaching patients how to monitor their symptoms, follow medication regimens, and make necessary lifestyle changes to improve their quality of life. Whether it’s managing asthma, diabetes, or hypertension, educating patients on self-management strategies is crucial to successful long-term outcomes.

Transcript

	Weight: 90 kg	Exam Action 03/19/23 2:01 AM EDT
	BMI: 31	Exam Action 03/19/23 2:01 AM EDT
	Random blood glucose: 238	Exam Action 03/19/23 2:01 AM EDT
	Blood pressure: 142/82	Exam Action 03/19/23 2:01 AM EDT
	Respiratory rate: 19	Exam Action 03/19/23 2:01 AM EDT
	O2 sat: 99%	Exam Action 03/19/23 2:01 AM EDT
	Heart rate: 86	Exam Action 03/19/23 2:01 AM EDT
	Height: 170.2 cm	Exam Action 03/19/23 2:01 AM EDT
	Temperature: 38.4 °C	Exam Action 03/19/23 2:01 AM EDT
	Hello. Am NURS 6512N Week 4 – Health History, Tina Jones Shadow Health , i will interview and examine you.	Greet 03/19/23 2:02 AM EDT
	Hey.
	What is your name?	Question 03/19/23 2:07 AM EDT
	Tina Jones.
	why are you here today?	Question 03/19/23 2:07 AM EDT
	I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now it’s looking pretty nasty. And the pain is killing me!
	Am sorry to hear that	Empathize 03/19/23 2:07 AM EDT
	I appreciate you telling me that.
	When did you get the scrape?	Question 03/19/23 2:09 AM EDT
	Well, I got the scrape a week ago, but the scrape and the pain got a lot worse in the last few days.
	How severe is the pain?	Question 03/19/23 2:10 AM EDT
	It’s really bad.
	Can you describe the pain?	Question 03/19/23 2:12 AM EDT
	It’s throbbing and like, sharp if I try to put weight on it.
	Did you hurt any other part? (Clarified to Did you hurt anything else during the fall?.)	Question 03/19/23 2:12 AM EDT
	Well, at first I thought my ankle was sprained because it hurt a lot right after I fell. But, I mean, I guess I was over-estimating it, because the ankle felt pretty okay the next day and it wasn’t a problem all week. (Clarified to if I hurt anything else during the fall.)
	How has the pain changed over time?	Question 03/19/23 2:13 AM EDT
	At first, it seemed like it was healing up fine and it didn’t give me a lot of pain. But the last two days, the pain got way worse.
	Does the pain radiate anywhere else?	Question 03/19/23 2:13 AM EDT
	The pain’s worse in my foot, but I feel it moving up into my ankle, too.
	How did you hurt your ankle?	Question 03/19/23 2:14 AM EDT
	I was going down the back steps, and I tripped. . . I caught the railing, but I guess I kind of turned my ankle a little bit. And I scraped up my foot on the edge of the step.
	Is it possible for you to stand on your foot?	Question 03/19/23 2:14 AM EDT
	No, I can’t put weight on my foot without really sharp pain.
	Can you rate your current pain level on a scale of 0 to 10?	Question 03/19/23 2:15 AM EDT
	I’d say a 7. It hurts a lot, and the pain pills haven’t kicked in yet.
	Can you tell me where the pain is located?	Question 03/19/23 2:19 AM EDT
	It feels like the pain is just centered around the scrape, like around the ball of my foot. That’s where it hurts the most, but my whole foot feels some pain.
	Which foot did you injure?	Question 03/19/23 2:19 AM EDT
	My right foot.
	Were you wearing shoes?	Question 03/19/23 2:20 AM EDT
	No, I was barefoot.
	Did you have any alcoholic drinks before the injury?	Question 03/19/23 2:20 AM EDT
	No, I was stone-cold sober. It was the middle of the day.
	Did you use home remedies for your foot?	Question 03/19/23 2:21 AM EDT
	Yeah, I made sure to clean it and keep it bandaged.
	What did you use to clean the er? (No matching questions found.)	Question 03/19/23 2:21 AM EDT
	What did you use to clean it?	Question 03/19/23 2:22 AM EDT
	Since it happened, I’ve been washing it with soap and water, and if it seemed irritated, I would put some peroxide on there and then rinse it off.
	When did you go to the er?	Question 03/19/23 2:22 AM EDT
	I went about an hour after I fell, I think.
	Did you get any medication at the ER?	Question 03/19/23 2:23 AM EDT
	Yes, they wrote me a prescription for some pain pills.
	Do you know the name of the pain pills?	Question 03/19/23 2:23 AM EDT
	It’s called tramadol.
	What dosage of tramadol?	Question 03/19/23 2:24 AM EDT
	I’m not 100% sure, but I think they’re 50 milligrams.
	How often were you taking the tramadol?	Question 03/19/23 2:24 AM EDT
	I’ve been taking the Tramadol morning, noon, and night. [AUDIO COMING SOON]
	Did tramadol relieve pain?	Question 03/19/23 2:25 AM EDT
	I’ve only been taking the pain pills the ER gave me and staying off it. . . and keeping the wound clean.
	Has your foot bled since the injury?	Question 03/19/23 2:25 AM EDT
	It’s not bleeding anymore. It only bled right after I scraped it.
	What happened after you scraped your foot NURS 6512N Week 4 – Health History, Tina Jones Shadow Health	Question 03/19/23 2:26 AM EDT
	I got the scrape to stop bleeding, and then I started to worry that I had sprained my ankle, so Mom and I decided better safe than sorry, and so we went to the ER.
	Its good to seek medical attention.	Educate 03/19/23 2:26 AM EDT
	That makes sense.
	Did the ER prescribe the pain pills?	Question 03/19/23 2:30 AM EDT
	Yes, they wrote me a prescription for some pain pills.
	Which pain pills were prescribed?	Question 03/19/23 2:31 AM EDT
	It’s called tramadol.
	How effective is the pain medication?	Question 03/19/23 2:32 AM EDT
	They only help for a few hours at a time.
	Am sorry to hear that.	Educate 03/19/23 2:32 AM EDT
	Thanks for telling me.
	How have you cared for the scrape?	Question 03/19/23 2:32 AM EDT
	I made sure to clean it and just keep it bandaged. And I put Neosporin on it.
	What happens after applying Neosporin?	Question 03/19/23 2:33 AM EDT
	I got the scrape to stop bleeding, and then I started to worry that I had sprained my ankle, so Mom and I decided better safe than sorry, and so we went to the ER.
	How effective is neosporin? (Clarified to How effective was the neosporin?.)	Question 03/19/23 2:33 AM EDT
	Well, I had to come back to get my foot checked out even though I used the ointment. [AUDIO COMING SOON] (Clarified to how effective the neosporin was.)
	How often have you been cleaning the scrape?	Question 03/19/23 2:34 AM EDT
	Since it happened, I’ve been washing it with soap and water, and if it seemed irritated, I would put some peroxide on there and then rinse it off.
	Its good to keep it clean.	Educate 03/19/23 2:35 AM EDT
	Alright, thanks for letting me know.
	Is the wound swollen? (Clarified to Is it swollen around the wound?.)	Question 03/19/23 2:35 AM EDT
	Yeah, it looks swollen around the scrape. (Clarified to if it is swollen around the wound.)
	Does your scrape have an odor?	Question 03/19/23 2:36 AM EDT
	Um, no, not that I know of… That sounds gross.
	Does the scrape have pus?	Question 03/19/23 2:36 AM EDT
	Yeah, there’s definitely pus.
	What color is the pus?	Question 03/19/23 2:37 AM EDT
	It’s… white or maybe off-white.
	Is the scrape red?	Question 03/19/23 2:38 AM EDT
	Yeah, it’s red all around the scrape.
	Any temperature change around the scrape?	Question 03/19/23 2:38 AM EDT
	No.
	Are you having trouble getting around?	Question 03/19/23 2:38 AM EDT
	Yes! I mean, I literally can’t put weight on my foot, the pain is so sharp.
	Am sorry to hear that.	Empathize 03/19/23 2:39 AM EDT
	Thanks for saying that.
	Who has been helping you at home since you hurt your foot?	Question 03/19/23 2:40 AM ED

Subjective Data Collection: 100 of 100 (100.0%)