Nursing Professional: Case Study

This case study explores the planning of person-centered care and effective communication in the nursing profession. It discusses the assessment of pain using the Numeric Rating Scale and PQRST assessment tool, as well as nursing interventions to reduce pain and improve communication with the patient. The case study also includes a background of the patient, assessment findings, and recommendations for care.

Running head: NURSING PROFESSIONAL: CASE STUDY
NURSING PROFESSIONAL: CASE STUDY
Name of Student:
Name of University:
Author’s Note:

1NURSING PROFESSIONAL: CASE STUDY
Answer 1: Planning person-centred care
a) To assess the pain of the patient in the simulation Numeric Rating Scale method
will be used in which subjective measures give the score of pain. The patient is
being investigated about the status of the pain and recorded vital signs. As seen
from the case study, the patient’s GCS scores 14/15. It tests the motor, eye and
verbal response of the patient. The score of 14 signifies that the patient is fully
awake and is in a conscious state of mind (Chandrasekhar et al., 2017). The
patient has shown a pupil eye rate of -2+, which reflect on the size of the pupil
that can be due to pain and discomfort. The patient was asked to describe about
the status of pain, where the score of 5 out of 10 was given that reflect moderate
pain. It is evident from the study of Nath et al. (2015) the pain could be due to fall
where the patient got an injury in the head. Other reason could be due to arthritis
where the joints and bone become stiffs and inflamed, which result in pain. The
study of Perrot et al. (2015) in injury and arthritis, damaged tissue releases
chemicals known as neurotransmitters and activate specific A-delta and C
sensory nerve fibres (nociceptors). The activation sends a signal to the brain to
response the motor nerve and results in pain.
b) Considering the past and current medical history of the Mr shepherd, to
comprehensively assess the pain PQRST assessment tool will be used as it
gives relevant information about the pain management and intensity of pain. The
tool consists of six-part, which include the following assessment steps:
PQRST assessment tool Steps were taken
P- palliation The patient was asked about the main

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reason for the occurrence of pain and
what action was taken during that
time. The answers will give insight
about the pathophysiology of pain,
which is needed to apply effective
nursing plan (Fink & Gallagher, 2019).
Q- quality The patient was asked to describe the
pain by some action or words which
would signify the intensity of pain.
R- Radiation The patient was investigated about the
location of pain and did the pain
radiate to a different location. The
patient describes the pain in the lower
back that remains located in a specific
position (Raina, Krishnappa & Gupta,
2018).
S- severity scale It is done to check the severity of the
pain by rating the pain in the scale of
10. 0 means no pain, 2-6 moderate
pain and above 6 till 10 huge pain
(Stephens, 2019). The patient scored
5 out of 10, which tells that pain is

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reasonable and not that severe.
T-timing The nurse investigated to the patient
about the time of the start of pain. The
information helps to give relevant
intervention that would help to lower
the pain (Ho et al., 2018).
The information collected highlight that the patient is having pain in the lower
back, which is due to arthritis and intensity of pain is moderate. All the answers
will be documented to plan effective nursing intervention.
c) The main goal of the nursing intervention would be to reduce the lower back pain
due to arthritis and make the patient mobile to do his daily living activities with
ease. In order to meet the desired goal, the following two most important
intervention would be taken by the nurse:
1. The nurse will provide hot and cold massage to lower the pain of the
patient. It is evident from the study of Rahayu et al. (2017) that heat
therapy is effective in relieving the stiffness of muscle and joint, which is
the frequent occurrence in arthritis. It eases the muscle spasm and helps
to warm the joint. Further, from the study of Vera et al. (2015), it is known
that cold therapy is efficient to reduce inflammation and swelling, which is
the primary cause of pain in arthritis.
2. The nurse would help to reposition the patient in a comfortable location
with the help of the firm mattress, small pillow and elevate the linens with

4NURSING PROFESSIONAL: CASE STUDY
bed cradle. The soft and sagging mattress help to prevent the
maintenance of proper body alignment, which helps to reduce the
pressure on the inflamed and painful joints (Wiggermann et al., 2019).
Answer number 2. Effective communication
Tool Reason
S- Situation The patient name is Mr Shepherd, who is
81 years old, having been reported with
lower back pain due to arthritis. He
appears to be a confused state of mind.
He had fallen and caused injury in the
head. The patient pain assessment has
reported having 5 out 10 score. The vital
sign note are
 Blood pressure 130/80
 BGL of 7.7
 Respiratory rate- 19/min
 GCS – 14/15
PQRST assessment showed he had
moderate pain in lower back pain. The
main concern area is discomfort due to
lower back pain (Kaasalainen et al.,
2015).

5NURSING PROFESSIONAL: CASE STUDY
B- Background The patient has a history of hypertension,
diabetes and asthma. The patient is
under daily medication for the injury in his
head (Lancaster, Westphal &
Jambunathan, 2015).
A-Assessment The NSR and PQRST assessment have
been done to evaluate the status of pain.
The evaluation revealed that there the
need to take care of the patient regarding
the lower back pain (Shahid & Thomas,
2018).
R-recommendation To improve the health of the patient, it is
recommended to the clinical nurse to
assist the patient so that the incidence of
fall can be reduced.
A patient must be assisted with daily
living activities (Chou et al., 2016).
The patient must be avoided getting out
of the bed as he is in a confused state,
which can again cause fall.

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The patient must be given effective
medication to reduce pain (Gordon et al.,
2016).
The patient must be placed in the
conformable position with the help of a
pillow.
The thickened fluid will be given to the
patient to swallow food easily (Marconati
et al., 2019).

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