Assess the Intensity of Pain: Nursing Assessment 2022

Task 1
Nursing assessment
Assess the intensity of pain
Mr. David is presented with multiple signs and symptoms during the time of admission. In
this case, the primary assessment needs to be carried out is assessment of pain. At the time
of admission patient was complaining of flank pain in the right side of the abdomen. The
patient is diagnosed to have acute kidney injury which induces the pain. Pain is the best tool
to identify clinical deterioration (Zuk, 2016). The primary cause for the pain is acute kidney
injury. The nurse must use the pain scale to assess the intensity of the pain. He is reported
with 2/10 flank pain on the right side. Continuously monitor the pain using pain scale and
patient’s expression. Document the pain score in the pain scale and report to the doctors if
increases (Kennedy, 2018).
Assessment of temperature
Mr. David is presented with acute kidney injury and pyelonephritis. He also has the past
medical history of chronic kidney disease. During the time of admission he is not febrile. But
he had a history of fever. His WBC count is increased, which indicates the infection.
Increased temperature is the symptomatic clinical data of internal infection (Ostermann,
2016). Continuous monitoring of temperature for every 2 -4 hours will provide the
information on intensity of infection. Regular monitoring and Identification of fever helps to
rate the infection. Temperature is monitored and recorded in the temperature chart (Vann,
2015).
Monitoring intake and output

Mr. David is presented with various disease conditions like acute kidney injury, chronic renal
disease, and pyelonephritis. All the disease condition damages the kidney cells and alters
the renal function. Main function of the kidney is the excretion of waste and fluid. The
patient is presented with decreased urine output, increased BP of 160/95mmhg, and
decreased glomerular filtration rate (Fishbane, 2017). All the symptoms of the patient and
pathology report clarify that there is the possibility of fluid retention. Fluid retention will
significantly increase the total blood volume and increase the load to the heart. Assessment
of fluid intake and urine output will provide the approximate data of total blood volume.
Fluid intake and urine output have to be documented in the intake and output chart.
Decreased urine output has to be reported to doctors.

Task 2
Nursing Care Plan: David Smith
Nursing problem: Acute Pain
Related to: renal injury and secondary pyelonephritis evident by the pain score of 2/10
Goal of care Nursing interventions Rationale Evaluation
The patient says
that pain and
increase comfort
Patient expresses that
he is aware of pain
reducing techniques
 Patient
regularly does
the deep
breathing
 Regularly assess the intensity of pain
using the pain scale
 provide diversion therapy
 Position the patient comfortably
 Encourage deep breathing exercise
 Administer analgesics as prescribed
(Song, 2015).
 Help the patient in mobilization
 Educate the patient and his family
about pain management technique
 Provide extra pillows
 The assessment provides a clear
picture of the problem
 Diversion therapy increases
comfort
 A simple technique to reduce
pain
 Relaxes the muscles
 Analgesics reduces the pain
 Mobilization increases blood
circulation and promotes
wound healing
The patient says that his pain is reduced
and he is aware of pain management
techniques for future execution.

exercise to
manage the
pain
 The patient is
able to move
the affected
part and
performs self
care by himself.
 Reassure the patient (Hayes, 2015).  Extra pillows promote comfort
 Reassurance and comfort boost
the patient’s confidence and
help him to cope with the pain
and disease condition (Hayes,
2015).
Nursing problem: Risk of fluid imbalance
Related to: the renal dysfunction and fluid retention
Goal of care Nursing interventions Rationale Evaluation
 The patient says
that he is aware
 monitor for signs and symptoms of
fluid imbalance
 Maintain intake output chart and
 Continuous monitoring helps to
identify the patient’s condition
 maintenance of intake output
Patient’s fluid imbalance is identified and
treated. The patient is hydrated. Pitting

of fluid
imbalance and
its causes.
 patient expresses
that fluid
restriction is the
essential aspect
of treatment
 patient
verbalises that
he is aware of
complications of
fluid imbalance
and the
complications
 The patient is
actively co-
report the decreased output
without delay
 Monitor vital signs
 Administer diuretics as prescribed
 Check and document the patient’s
weight
 Watch for abnormal sounds on
auscultation of lungs (Clarke, 2016).
 Assess pitting oedema and skin
integrity in the place
 position the patient in semi fowlers
chart provides the data about
fluid balance
 Vital signs provide information
about the patient’s condition
 Diuretics remove excess fluid
 Increase in weight indicates
increased fluid retention
 Abnormal lung sounds indicate
fluid retention
 oedema can break the skin and
cause infection
 Semi fowlers position supports
normal breathing
oedema is reduced.