Pain Paper - He has an elevated temperature, pulse and...

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Jennifer Franks 10-1-2010 Acute Pain A young boy and his mother enter the ER at 2:32 pm. He is holding his lower right arm. The mother explains that he fell off of the fireman’s pole during recess at school. An x- ray is ordered. Health History The admissions data reveals the patient is Noah Smith. He is 4 foot 2 inches tall, weighs 42 lbs., and has a temp. of 99.1, a pulse of 98, respirations of 24, and a bp of 108/68. He is currently being treated for asthma. His medication regimen includes one puff of Advair 50/100, one spray of Nasonex in each nostril and 5mg of Singulair once a day. Characteristics of Pain The client has verbalized his arm is in pain. He cries when it is moved and winces when sitting still. He continues to hold the arm as if to guard it. Objective Data The sagging of Noah’s right lower arm is indicative of a break.
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Unformatted text preview: He has an elevated temperature, pulse and blood pressure reading. Communication with the Client The client explained that when he fell, he put his arms out to break his fall. He thinks his arm is broke because it is shaped like an S. He claims it doesnt hurt too bad as long as he doesnt move. Pain Scale The Wong-Baker FACES pain rating scale of 0-5 was used. The patient chose 2 when sitting still, and 4 when being moved. Nursing Diagnosis The nursing diagnosis is Acute pain due to physical trauma. A related nursing diagnosis would be activity intolerance due to pain. Pain Management After his arm was reset and a cast was put on, a prescription of Tylenol was ordered for every 4 hours as needed....
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Pain Paper - He has an elevated temperature, pulse and...

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