1. Pt verbal reports of pain level between 6-8 r/t R fractured ribs.2. Patient has decreased bowel elimination and motility r/t poor p/o intake.3. Pt has difficulty coping with pain4. Increased respiratory/heart rate with exertion and movement.5. Pt has deficient knowledge concerning regulation of pain and states, “I’m in the hospital; I don’t understand why they don’t have my pain under control and at a zero pain level.”1. Patient’s pain will be maintained at a level 3 using the pain rating scale before end of shift. 2. Patient will verbalize importance of increasing fiber nutrients in diet before discharge.3. Pt will describe coping strategies, such as distraction and relaxation before end of shift. 4. Pt will maintain a respiratory and heart rate wnl after ambulation of 40 feet to/from BR prior to discharge.5. Pt will verbalize the importance of adequate pain management prior to discharge.1. Pain rating scale (0-10) to monitor pain level.2. Pt recall test after education.3. Patient demonstration of effective coping techniques4. V.S/O2 sat/Fatigue rating measurement5. Pain management recall test after educationOutcome State Present StateInterventions on next pageExit Framing: Pt. is slouched over in bed and looks fatigued. She has yellowed end-stage bruising around her eyes and abrasions to her face. Pt is watching television and breathing heavily. PCA in place and the pt-contolled button is consistently pressed.Reflective SRL Journal promptsCue LogicAcute Pain (11)Activity Intolerance (6)Fatigue (6)Imbalanced Nutrition: less than body requirements (6)Impaired Gas Exchange (6)Constipation (5)Risk for impaired skin integrity (5)Ineffective Coping (4)Risk for Falls (4)Self-care deficit (4)Keystone Issues: Acute PainPatient-in-Context StoryPt is a 54 y/o white female. Admitting dx is R rib fractures and R PTX. Past health hx is BTL/DTS in 2008. History of depression and crack/cocaine/alcohol use. Family hx is unknown. Pt has a h/o physical abuse and hospital visits due to past trauma. Pt is on substance abuse consults with alcohol w/d protocol. No allergies. Pt is a self-employed construction worker for husband. She is married, but relationship was unable to be assessed. Upon entering room, the husband didn’t speak. Vital signs: T-98.2 degrees, P-78, R-20, B/P-112/76. Pt. describes excessive pain, rating it as an 8 on a 0-10 rating scale. She describes pain as a stabbing pain on the R side of the chest. She also states that “when walking and moving my left arm, I have a pain that shoots through my right breast.” Pt expresses difficulty breathing and increased pain upon inhalation and exhalation when not given her medications promptly. Respiratory assessment: Regular and unlabored breathing, clear lung sounds on the RUL and LUL. Middle and lower portions of both right and left lung are crepitus. Pt has a cough, secreting a yellow-green sputum. No supplemental oxygen, but presence of a R chest tube, draining serosanguinous fluid. O2 sat on R hand is 92%. Heart rate is 74 bpm, regular, palpable pulses bilaterally, cap refill <2 seconds. Extremities are warm to touch, no edema. Skin has a yellow/pale appearance with yellowed bruising and edema around the eyes. Erythematic abrasions (open to air) on the nose, chin, elbows, L side of pelvis, knees and ankles. Mucous membranes are moist and intact. Braden score of 17. EENT assessment was wnlx presence of abrasions around the eyes and on the nose. Pt walked one time throughout the day and was OOB to bathroom. Pt groans during walk to the bathroom because of increased pain. She stated throughout the day, “There is no way that I can live if I don’t have medicine now.” Pt is in bed most of day with impaired nutritional intake. Pt also had chest x-ray scheduled and the PA for the chest x-rays described his concern with an air pocket in her RUL that would have to be removed if the lung did not eventually adhere the outer surface of the lung to the wall. After chest tube suction is turned off, her lung collapsed. Pt’s Medications: Morphine PCA, Sennosides-Docusate, Lorazepam, Multivitamin with minerals, Thiamine HCl (Vit. B-1), Folic acid, Enoxaparin Sodium (Lovenox), Citalopram Hydrobromide, Paroxetine HCl, Tiazodone HCl, Nicotine, Nonformulary, Bacitracin Zinc, Ibuprofen, Active PRN: Diphenhydramine HCl, Morphine Sulfate, Ondansetron HCl, Oxycodone, Haloperidol, Mg Oxide, Haloperidol oxide, Naloxone HCl. CBC with differential: RBC-3.72L, MCV-100.0H, MCHC-32.0L. Basic Metabolic: BUN-5L, Calcium-8.4L, Glucose-113H, Sodium-135L. Triage Urine Drug: Benzodiazepine Positive A+, Cocaine Positive A+, Opiates Positive A+. ED Trauma: PH (V)-7.257L, PCO2-54.6HJudgments1. Goal was partially maintained. Pain level was assessed at different intervals and a pain level between 3-5 using the pain rating scale. The pt expressed happiness concerning the decrease in pain.2. Goal was met. Pt verbalized the importance of eating foods high in fiber and gradually increased the overall intake of food p/o.3. Goal was met. Pt. engaged in activities such as deep breathing and distraction methods (reading a book and crossword puzzles).4. Goal was unable to assess because of inadequate time before discharge. Overall, pt’s respiratory rate still increased significantly with exertion.5. Goal was met. After education, pt verbalized her understanding concerning a “lowered pain level” instead of a completely absent (0) pain level.Interventions1. Assess pain in the client by using a self-report such as the 0 to 10 numerical pain rating scale, Wong-Baker FACES scale, of the Faces Pain Scale.2. Ask the client to describe appetite, bowel elimination, and ability to rest and sleep. Administer treatments to improve these functions. Obtain a prescriptionfor a stool softener plus a peristaltic stimulant to prevent opioid-induced constipation if needed. 3. In addition to the client’s use of analgesics, the client will use nonpharmacological methods to help control pain, such as distraction, imagery, relaxation, and application of heat and cold.4. When opioids are administered, assess pain intensity, sedation, and respiratory status at regular intervals. Assess sedation and respiratory status every 2 hoursfor the first 24 hours of therapy. Awake sleeping clients for further assessment if they have an inadequate respiratory rate; shallow, irregular, or noisy (snoring) respirations; or apneic episodes.5. Explain to the client the pain