Integrated Nursing Practice: Pain Management Comparison and Intervention

This essay compares and contrasts the difference in symptoms and its corresponding reasons to implement adequate care interventions based on the chosen problem of pain. It also discusses the SMART goals and interventions for pain management for two different patients.

Running head: INTEGRATED NURSING PRACTICE
Integrated nursing practice
Name of the student:
Name of the university:
Author note:

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INTEGRATED NURSING PRACTICE
Introduction:
The nursing care needs to be optimally effective in order to be addressing the care
needs of the patients efficiently. However, the care needs of the different patients are
different, and hence, it is crucial for the care interventions to also be individualized for each
of the patients. On a more elaborative note, even though the patients are exhibiting similar
symptoms, the pathophysiology and underlying cause behind the care interventions can be
very different from each other, and hence, it is imperative for the nurses to understand the
difference in the pathophysiology of the similar symptoms expressed by the different
patients. This essay will attempt to compare and contrast the difference in symptoms and its
corresponding reasons to implement adequate care interventions based on the chosen problem
of pain.
Assessment data and pathophysiology:
It has to be mentioned that clinical reasoning cycle provides a systematic
framework for the nurses to collect and interpret assessment data along with processing them
and arriving at a verdict regarding priority nursing problems of the patient (Dalton, Gee &
Levett-Jones, 2015). In the case the processing of the assessment data can provide significant
insight to the similarities and differences in the cases of both Anna and George. The first case
study selected for this comparison is of Anna Hayes, who is a 4 year old girl admitted to the
facility complaining of pain. The assessment data for the patient indicates history of vomiting
and diarrhoea along with abdominal pain. The current medication indicates that the patient
had been administered paracetamol suppository and oral syrup in every hours. Although her
abdominal pain has not completely subsided even after the medication administration. Her
pain score is 6/10 which is considered to be moderate pain bordering on becoming severe
(Joseph & Godwin, 2016). The results of her vital sign assessment indicates temperature 38.2

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0 C, BP 88/50, HR 118, R 22, SpO2 98% on room air, Weight 16kg. The consciousness
assessment data reveals the fact that Anna is drowsy, yet rousable and starts to cry when she
is awaken, possibly due to the pain and discomfort that she is feeling due to her symptoms.
According to the signs and symptoms that Anna has been exhibiting it is clear that she had
been suffering from viral gastroenteritis. As mentioned by Corcoran, Van Well and Van Loo
(2014), viral gastroenteritis is associated with clinical manifestations including watery stools,
nausea and vomiting and moderate to severe abdominal cramps, all of which had been
experienced by Anna as well. Anna also had mild fever which can be the innate response of
her body to the intestinal infection. The hypotension at 88/52 BP that she had been suffering
from can be due to the extreme watery stools, vomiting and fever which also has disrupted
the electrolyte balance of the body leading to a drop in oxygen availability of the body. This
is also the factor contributing to high respiratory rate and high heart rate compensating for the
disrupted oxygen availability of the body.
On the other hand, the next patient in comparison is the George McAdams who had
been suffering from GORD or the gastro-oesophageal reflux disease. George also had very
similar symptoms of vomiting and diarrhoea. The priority problem for him has as well been
abdominal pain. However, his condition and the pathophysiology if the clinical
manifestations had been very different to that of Anna. He is a frail, 85 year old man who had
past medical history of GORD (Garg & Gurusamy, 2015). GORD is gastro-oesophageal
reflux disease which leads to various abdominal complications. His vitals include
Temperature 38.2 C, HR 108 (irregular), BP 105/60, RR 22, and SpO 2 99%. Although, the
patient in this case had been experiencing symptoms that suggests viral gastroenteritis, acid
reflux has been also reported to cause vomiting and diarrhoea and well. As mentioned by the
Kang et al. (2018), the acid reflux causes considerable damage to the intestinal muscles
which in turn loses some degree of its functionality which eventually leads to stool

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incontinence and abdominal cramps. Along with that, in GORD, the lining separating the
stomach and oesophagus is destroyed which leads to food, fluid mixed with stomach acids to
back up in the oesophagus and into the mouth of the patient due to poorly functioning LES.
Hence, although the symptoms of both the case studies have been similar, the
pathophysiology in Anna’s case differed from that of George.
SMART goals:
As per the clinical reasoning cycle, after the step of processing assessment
information and identifying the priority care needs, the next most possible step is setting
achievable goals for the patients (Dalton, Gee & Levett-Jones, 2015). The importance of
establishing achievable goals for the patients has also been illustrated in the standards of the
registered nurse practice standards by NMBA (Nursingmidwiferyboard.gov.au, 2018).
According to the 5th standard, the nurses are also required to utilize the assessment data to
develop a plan and establish goals collaboratively with the patient. In this case, the priority
problem selected for both of the case studies is abdominal pain, the goal will be set taking the
assistance of the SMART goal framework.
For Anna the SMART goal will be to decrease the abdominal pain from 6 out of 10 to
2 out of 10 within the next 24 hours with the help of fluid therapy and 240 mg paracetamol as
per the weight of the patient (16 kg) twice in a day and relaxation based meditation
techniques as alternative pain management intervention.
Specific Measura
ble
Achievable Realistic Timely
Pain will
decrease
From
6/10 to
2/10 as
Oral paracetamol after being
absorbed by the gut will release
analgesic effect that lasts for 4-6
With relaxation or
meditation and
weight adjusted
Within
24 hours

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measure
d by pain
scoring
tool
hours which will help in relieving
the pain felt. The intervention of
relaxation technique and meditation
interventions such as breathing
exercises will distract the patient
and will help in better pain
management.
dosage of
paracetamol
(standard
treatment
intervention for
stomach flu,
hence realistic )
For George, the care plan will be to reduce the pain felt by thee patient from 6/10b to
2/10 within the next 24 hours by the administration of Tylenol or acetaminophen which will
help in reducing the abdominal cramping pain felt by George with acupuncture as an
alternative management of pain.
Specific Measura
ble
Achievable Realistic Timely
Pain will
decrease
From
6/10 to
2/10 as
measure
d by pain
scoring
tool
Oral Tylenol is an NSAID
medication which can been
approved for use in older adults
above the age of 60 and does not
irritate the stomach, by reducing the
production of prostaglandin and
enhancing the pain sensation
threshold of the patient within 20-
40 minutes
With acupuncture
and age adjusted
dosage of
Tylenol, the pain
will gradually
subside
Within
12-24
hours

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Interventions:
The chosen issue for the case study is pain management for both the cases, however
the intervention approach will differ slightly in case of both of the patients depending on the
condition and its pathophysiology.
For Anna, the first nurse initiated intervention will be administration of the
paracetamol with the eight adjusted dosage for Anna, taking into consideration her age and
her weight significantly. It is very important for the nurse to take into consider the fact that
dosage calculation and administration details must adhere to the safe practice guidelines in
order to ensure optimal safety of the child (Star & Choonara, 2015). The rationale for
paracetamol administration for Anna is the fact that it is a non-opioid based analgesic which
has least side effects, hence it is by far the safest medication to be given to the children.
Along with that, the safest protocol to administer paracetamol to children is to adjust dose
with the weight of the child, hence giving weight adjusted dose of paracetamol to Anna is a
best practice intervention. The second intervention will be to implement is meditation and
relaxation therapy. As rationale for this choice, meditation and relaxation has emerged as a
very common and abundantly used technique for pain management, especially in children
patients. Along with that, in contrast of acupuncture which was chosen for George, which is
an invasive, critical and complex procedure involving needles. Such intervention techniques
can scare and irritate the child which can lead to further complications. Contrastingly, the
relaxation session with meditation and breathing exercise is a much safer and easy to
implement alternative for Anna (Fisher, Law, Palermo & Eccleston, 2015).
On the other hand for George, although the interventions chosen are similar but will
need to be modified with respect to his care needs and his age. First and foremost, as his
symptoms are aggravated by GORD, the choice of analgesic for him will be Tylenol, as the
first nurse initiated intervention to achieve the goals. As discussed by the Kiguli et al. (2014),

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Tylenol is also a non-opioid based analgesic, being a NSAID drug as well, it is safe to be
used for patients that are above the age of 60. Along with that, acid reflux already has a
significant impact on the stomach making it more sensitive, Tylenol has no irritable impact
on the stomach. Hence, Tylenol with dose adjusted for his age was given to him (Lanata et
al., 2013). The second intervention will be to implement is acupuncture with the collaboration
from alternative medicine expert. As rationale for this choice, acupuncture has emerged as a
very common and abundantly used technique for pain management, especially in elderly
patients with back pain, headaches and stomach aches. This is an effective and safe
alternative therapy for pain for children, hence, it can be of good use for George (Çevik, Anıl
& İşeri, 2015).
The evaluation indicator for pain for both of the patient will be pain score assessment
periodically and frequently. In case of Anna, FLACC scale can be used and in case of
George, PQRST scale can be used. For non-pharmacological pain management, the
evaluation indicator will be to check the facial expression of the patient and hacking whether
they are calming down. In this case however, the indicators for both of them will be similar
(Reddy, Weinberg & Young, 2016).
Conclusion:
This case study provided ample opportunity for me to implement NMBA nursing
standards and clinical reasoning cycle in the practice scenario. Along with that this case study
assignment also gave me the opportunity to explore the difference in pathophysiology of
different patients and their care needs and differentiate the care interventions that are
applicable for Anna’s case and George’s case. It can be hoped that this experience will help
me improve the practice.

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References:
Abu Naser, S. S., & El-Najjar, A. E. (2016). An expert system for nausea and vomiting
problems in infants and children. Retrieved from
https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2814417
Bennett, S. (2016). Pharmacology and prescribing of paracetamol: an update. Nurse
Prescribing, 14(9), 450-456. Doi: 10.12968/npre.2016.14.9.450
Çevik, C., Anıl, A., & İşeri, S. Ö. (2015). Effective chronic low back pain and knee pain
treatment with acupuncture in geriatric patients. Journal of back and musculoskeletal
rehabilitation, 28(3), 517-520. Retrieved from
https://content.iospress.com/articles/journal-of-back-and-musculoskeletal-
rehabilitation/bmr550
Chen, S. Y., Tsai, C. N., Lee, Y. S., Lin, C. Y., Huang, K. Y., Chao, H. C., ... & Chiu, C. H.
(2017). Intestinal microbiome in children with severe and complicated acute viral
gastroenteritis. Scientific reports, 7, 46130. Retrieved from
https://www.nature.com/articles/srep46130
Corcoran, M. S., Van Well, G. T. J., & Van Loo, I. H. M. (2014). Diagnosis of viral
gastroenteritis in children: interpretation of real-time PCR results and relation to
clinical symptoms. European journal of clinical microbiology & infectious
diseases, 33(10), 1663-1673. Doi: 10.1007/s10096-014-2135-6
Dalton, L., Gee, T., & Levett-Jones, T. (2015). Using clinical reasoning and simulation-based
education to'flip'the Enrolled Nurse curriculum. Australian Journal of Advanced
Nursing, The, 33(2), 29. Retrieved from
https://search.informit.com.au/documentSummary;dn=018184224173600;res=IELHE
A

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De Lauretis, A., Visca, D., Ward, S., Clayman, C., Murray, C., Voon, O., ... & Aiello, M.
(2015). Gastro-oesophageal dismotility measurements in scleroderma-associated
interstitial lung disease: Correlation with respiratory and reflux symptoms. Doi:
10.1183/13993003.congress-2015.PA3805
Fisher, E., Law, E., Palermo, T. M., & Eccleston, C. (2015). Psychological therapies
(remotely delivered) for the management of chronic and recurrent pain in children and
adolescents. The Cochrane database of systematic reviews, 3, CD011118.
doi: 10.1002/14651858.CD011118.pub2
Garg, S. K., & Gurusamy, K. S. (2015). Laparoscopic fundoplication surgery versus medical
management for gastro‐oesophageal reflux disease (GORD) in adults. Cochrane
Database of Systematic Reviews, (11). Doi:
10.1002/14651858.CD003243.pub3/abstract
Giordano, M., Ciarambino, T., Castellino, P., Malatino, L., Di Somma, S., Biolo, G., ... &
Adinolfi, L. E. (2016). Diseases associated with electrolyte imbalance in the ED: age-
related differences. The American journal of emergency medicine, 34(10), 1923-1926.
doi: 10.1016/j.ajem.2016.05.056
Joseph, G., & Godwin, A. (2016). Viral Gastroenteritis among Children under 5 Years in
Dutsinma Local Government Area, Katsina State, North-West Nigeria, West
Africa. Open Access Library Journal, 3(02), 1. Retrieved from
http://file.scirp.org/pdf/OALibJ_2016071311362708.pdf
Kang, B., Lee, H., Choi, Y., Jeon, C., & Lee, J. A. (2018). Banxia Xiexin tang for gastro-
oesophageal reflux disease: A protocol for a systematic review of controlled
trials. Medicine, 97(17). doi: 10.1097/MD.0000000000010393

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INTEGRATED NURSING PRACTICE
Lanata, C. F., Fischer-Walker, C. L., Olascoaga, A. C., Torres, C. X., Aryee, M. J., & Black,
R. E. (2013). Global causes of diarrheal disease mortality in children< 5 years of age:
a systematic review. PloS one, 8(9),
e72788.https://doi.org/10.1371/journal.pone.0072788
Mason, D. G. (2017). Fifteen-minute consultation: Pain relief for children made simple—a
pragmatic approach to prescribing oral analgesia in the postcodeine era. Archives of
Disease in Childhood-Education and Practice, edpract-2016. Retrieved from
https://ep.bmj.com/content/early/2017/06/14/archdischild-2016-311613
Nursing and Midwifery Board of Australia - Professional standards. (2018). Retrieved from
https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/
professional-standards.aspx
Reddy, S., Weinberg, L., & Young, P. (2016). Crystalloid fluid therapy. Critical Care, 20(1),
59. https://doi.org/10.1186/s13054-016-1217-5
Star, K., & Choonara, I. (2015). How safe is paracetamol?. Retrieved from
https://adc.bmj.com/content/100/1/73.short