BSN 2-J / NCM 106 – Pharmacology (2023-2024)

BRAGA, SHANE ANN L.

Activity 2: Case Study

Case study:
Mr. John, is a 66-year-old man who just arrived in the Surgical ward following removal of
the appendix. He is complaining of pain on the operative site. You are the nurse assigned to
care for Mr. John. Basing from the Nursing Process, answer the following questions:

1. What critical assessment data do you need to identify and collect?

a. Pain Assessment: Assess the location, intensity, quality, and duration of Mr. John's
pain. Use a pain scale to quantify his pain level.
b. Vital Signs: Monitor vital signs, including blood pressure, heart rate, respiratory rate,
and temperature. Changes in vital signs can indicate pain or other complications.
c. Surgical Site Assessment: Inspect the surgical site for signs of infection, such as
redness, swelling, warmth, or drainage. Note any signs of dehiscence or evisceration.
d. Medication History: Inquire about any allergies or sensitivities to medications. Ensure
Mr. John's pain medications are up to date and administered as prescribed.
e. Medical History: Review Mr. John's medical history, including any pre-existing
conditions or chronic illnesses that may affect his recovery.
f. Fluid Intake and Output: Monitor Mr. John's fluid intake and output to ensure adequate
hydration.
g. Bowel Sounds: Assess bowel sounds to monitor for postoperative ileus.
h. Level of Consciousness: Observe his level of consciousness and mental status to
identify any signs of neurological complications.

2. Formulate a Nursing Diagnosis based on your assessment data.

Based on the assessment data, a potential nursing diagnosis for Mr. John could be:
Acute Pain related to surgical incision and tissue trauma

3. Describe two nursing interventions to assist the patient.

Nursing Interventions to assist the patient:

a. Pain Management:
 Administer pain medications as prescribed, ensuring proper dosage and
timing.
 Encourage the patient to use pain scales or verbalize their pain intensity
regularly.
 Use non-pharmacological pain reduction approaches such as relaxation
exercises, distraction, or positioning to maximize comfort.
 Educate the patient about the necessity of promptly reporting pain and any
negative effects of pain drugs.
b. Wound Care and Monitoring:
BSN 2-J / NCM 106 – Pharmacology (2023-2024)
BRAGA, SHANE ANN L.
Activity 2: Case Study
 Perform wound care as ordered, keeping the surgical site clean and dry.
 Monitor for signs of infection, such as increased redness, swelling, or pus.
 Educate the patient on wound care instructions and signs of complications to
report.

4. What criteria would you use to evaluate the effectiveness of the nursing
interventions?

a. Pain Relief: Assess if the patient's pain level decreases or remains within an acceptable
range based on their self-reported pain ratings. Assess the patient's capacity to carry out
activities comfortably.
b. Wound Healing: Inspect the surgery site for symptoms of infection or delayed healing.
Determine whether the wound is healing without issues.
c. Patient Education: Examine the patient's comprehension of pain relief techniques and
wound care instructions. Ascertain that Mr. John can show correct wound care practices
and recognizes indicators of infection or problems that should be reported.
d. Vital Signs: Check if vital signs (e.g., blood pressure, heart rate) stabilize within
acceptable ranges and do not indicate any worsening condition.
e. Patient Satisfaction: Gauge the patient's satisfaction with their pain management and
overall care. Address any concerns or issues promptly.

Regular reassessment and communication with the patient are essential to adjust
interventions as needed to ensure a successful recovery.