Nursing Assessment and Concerns for a Patient with Back Pain Following a Fall

QUESTION

Ann Rails is a 24-year-old who came to the emergency department early this morning with reports of back pain. The client’s partner stated that the client “fell from a step ladder.” Multiple bruises were noted on the client’s right forearm, back, and face in varying stages of healing. Current vital signs are Temperature 37° C (98,6° F), Pulse 94/min, Respirations 20/min, BP 128/86 mm Hg, and 5pO: 98% on room air. The client received hydrocodone/acetaminophen 2 hr ago for pain of 6 on a scale of 0 to 10. On reassessment, the client rated the pain as 2 on a scale of 0 to 10. The client’s partner remains at the bedside. 0715 – The nurse reviews the information received in report. Which of the following concerns should the nurse address while providing client care? (Select all that apply.) • Safety: Injury prevention [ Safety: Self-harm Physiological: Comfort • Physiological: Gas Exchange © Physiological: Mobilty • Physiological: Pain Physiological: Sensory Physiological: Perfusion Physiological: Tissue Integrity • Physiological: Nutrition

ANSWER

Nursing Assessment and Concerns for a Patient with Back Pain Following a Fall

Introduction

Ann Rails, a 24-year-old patient, presents at the emergency department with complaints of back pain after reportedly falling from a step ladder. The patient’s condition requires a comprehensive nursing assessment to address concerns related to safety, comfort, and overall well-being. This essay will discuss the nursing concerns that should be addressed while providing care to Ann Rails.

Assessment Findings

Multiple Bruises: Ann has multiple bruises on her right forearm, back, and face in varying stages of healing. These bruises raise concerns about the cause of the injuries and whether there may be ongoing safety issues, including potential abuse or self-harm.

Pain Management: Ann received hydrocodone/acetaminophen for pain management and initially reported a pain level of 6 on a scale of 0 to 10, which decreased to 2 after medication. Continuous pain assessment is essential to ensure adequate pain control.

Vital Signs: Ann’s vital signs, including temperature, pulse, respiration rate, and blood pressure, have been monitored and appear within normal limits. However, ongoing monitoring is necessary to detect any changes or deterioration.

Nursing Concerns

Safety: Injury Prevention: The presence of multiple bruises, combined with the reported fall from a step ladder, raises concerns about the safety of Ann’s living environment. The nurse should assess for any environmental hazards and provide education on injury prevention to both the patient and her partner.

Safety: Self-Harm: The bruises on Ann’s body could be indicative of self-harm or abuse. It is crucial for the nurse to assess Ann’s mental and emotional well-being, inquire about the cause of the injuries, and provide emotional support and resources if necessary.

Physiological: Comfort: Pain management is a priority for Ann. The nurse should continue to assess her pain levels, ensure the effectiveness of pain medications, and provide alternative pain relief interventions if needed.

Physiological: Mobility: Back pain can significantly affect a patient’s mobility. The nurse should assess Ann’s ability to move, offer mobility aids if necessary, and promote safe movement to prevent further injury.

Physiological: Nutrition: While not explicitly mentioned in the scenario, assessing Ann’s nutritional status is essential for overall well-being and healing. The nurse should inquire about her dietary intake and offer dietary counseling if needed.

Conclusion

Providing care for Ann Rails, a patient with back pain following a fall, involves addressing multiple nursing concerns related to safety, pain management, comfort, mobility, and overall well-being. The nurse’s role is to conduct a comprehensive assessment, ensure adequate pain control, promote safety, and offer emotional support as needed. By addressing these concerns, the nurse can contribute to Ann’s recovery and well-being while providing holistic patient-centered care.