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RUNNING HEAD: DECISIONAL ANALYSIS

Decisional Analysis Paper

Emma Kenney
NURS 627
March 20, 2014
Professor Simonton
DECISIONAL ANALYSIS 2

In the clinical setting, I was caring for a patient on a medical/surgical floor following the
removal of a gallbladder. The patient had been at the hospital for three weeks and was becoming
very irritable and aggravated as the day went on. I tried several different personal strategies to
get the patient to allow me to help care for him, none of which were successful.
As the day went on, I noticed that the patient was a little more receptive to the LNA
caring for him. The patient seemed to have established a relationship with him as he had been
here for quite some time. In order to help relieve some of the patients irritability and allow me
to properly care for the patient, I tried to incorporate my care during times in which the LNA was
in the room. The patient would allow me to care for him after the LNA and I both explained
what I was doing and why it was important to his current stay. When the patient was becoming
aggravated the LNA was able to calm him down.
Working with the LNA was successful for some time, but I realized that I was going to
need to figure out another strategy as the LNA would not always be available. I also knew that
according to the other nurses this behavior was not typical for the patient; I needed to get to the
bottom of this as his student nurse. I decided to try and figure out if there were factors that could
be attributing to him being reluctant to my care and extremely irritable.
I decided to begin looking at the patients chart for previous assessment findings that may
be helpful. I looked back at the patients vital signs over the last few hours and noticed that there
was a steady increase in his heart rate, blood pressure, and respiratory rate. I also noticed that the
patient had several orders for as needed (PRN) pain medication that had not been administered in
several days.
This did not seem odd to me as I it was documented that he denied pain several times
throughout each nurses shift. The pain assessment that I performed on the patient this morning
DECISIONAL ANALYSIS 3

included: precipitating factors, the quality, if the pain radiated the severity, timing, and the
location. My assessment, too, resulted in the patient denying being in any pain. I soon began to
think otherwise when I witnessed him guarding his abdomen and grimacing while he ambulated
to the restroom.
Based upon the pain assessment tools provided by the hospital, his vital signs, body
language, and his mood I decided that the patient was definitely experiencing quite a bit of pain.
I did not understand why the patient did not speak up. He had medication that could help him be
more comfortable and lessen the severity of the pain. I then remembered a discussion in post-
conference in clinical a few weeks back about pain culture.
In this discussion, I learned that everyone has their own pain culture. Some people do not
like to take pain medication or admit that they are in pain as they are afraid that it is a sign of
weakness. An individuals culture may encourage avoidance of pain or to accept it as a part of
the life experience. In this way, culture becomes the conditioning influence in the formation of
the individual reaction patterns to pain (Davidhizar, 2004). This seemed to apply to my patient.
I understood that my patient was not going to admit that he was in pain, but I still wanted to
figure out a way to make him more comfortable.
I went back into my patients room and reminded him that he had pain medication he
could take if he needed it. My patient denied the need for medication, which was not surprising. I
felt that for this patient alternative pain interventions would be best. I felt that my patient would
be more willing to accept these measures as they would appear as comfort care instead of pain
interventions.
I suggested that my patient try sitting in his chair in the reclined position since he had
been in bed for the majority of the day. I knew that this position would relieve the pressure on his
DECISIONAL ANALYSIS 4

abdomen that he had from sitting upright in bed all day. Fortunately, the patient was very eager
to move to the chair. Once he was reclined in his chair, I told him that I was going to bring him
some warm blankets. I decided to provide warm blankets as I knew that heat can be comforting
for someone in pain. I also turned the television on for the patient as a form of distraction.
I told the patient that I was going to leave him alone for a little while so he could rest, but
to use his call bell if he needed anything. Before leaving, I closed the blinds so the room was not
as bright and shut the door behind me to eliminate additional noise that could be aggravating to
the patient. I was also hoping that these interventions would help encourage the patient to rest as
well.
About an hour later I needed to obtain vital signs from the patient. I walked in and found
my patient sleeping in his chair. I was trying to be as quiet as possible as I did not want to wake
him. I was really nervous when my patient woke up while I was taking his blood pressure
because I thought for sure that he was going to be very upset with me like he had been
throughout the day. I apologized to the patient and to my surprise he was very understanding.
With a smile on his face he said, Dont worry about it. Do what you have to do. I was
absolutely shocked as this was not the response I was expecting at all. Due to the patients blood
pressure and heart rate returning within normal limits and improvement in his mood, I felt that
my interventions had been very successful. I was able to care and perform my tasks as the
student nurse for the rest of the day and the patient appeared to be a lot more comfortable and
more approachable than he had before.
Looking back on this situation, I felt at the time that I was doing something wrong or the
patient did not like me, which was why he was not allowing me to care for him. Instead of trying
to change myself for the patient, I should have picked up on the assessment data I was getting
DECISIONAL ANALYSIS 5

while being in the patients room. Had my focus been on the patient, I would have figured out he
was in pain a lot sooner.
If this situation came up again I think that I would use my pain assessment resources and
assessment findings quicker to determine an appropriate nursing intervention. I feel that I would
use the same interventions as they were very effective. Depending on the age of the patient,
location of the pain and the type of pain the patient was experiencing some of the interventions
may change slightly. For example, ice instead of heat etc.
I would describe the process I used in my clinical decision making as a combination of
scanning the environment for knowledge and quality patient outcomes. This is because I
gathered a lot of data from observing the patient and his behaviors while in his room. I also
specified my interventions that I felt would provide the best outcomes for my patient. I tried to
individualize them based upon his location and type of pain as well as his reluctance to
pharmacological interventions.
Based upon the evidence, I would not change my decision. According to the evidence, I
feel that I did exactly what I was supposed to do. I used the proper assessment tools to evaluate
and determine that my patient was experiencing pain. While assessing the patient, I used his
vital signs to determine that he was experiencing pain. The physiological effects of pain are
profound on the cardiovascular, respiratory, and musculoskeletal systems. Changes in patients
vital signsincreased heart rate, increased respiratory rate, and increased blood pressureare
strong indicators for inadequate pain control for the postoperative patients (Nworah, 2012). I
also completed a pain assessment that included the following: The assessment should include a
description of the pain: its location, duration, frequency, intensity, aggravating and relieving
factors (Godfrey, 2005).
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According to Davidhizar, Seven strategies can assist in culturally appropriate
assessment and management of pain: (1) utilize assessment tools to assist in measuring pain, (2)
appreciate variations in affective response to pain, (3) be sensitive to variations in
communication styles, (4) recognize that communication of pain may not be acceptable within a
culture, (5) appreciate that the meaning of pain varies between cultures, (6) utilize knowledge of
biological variations, and (7) develop personal awareness of values and beliefs which may affect
responses to pain (Davidhizar, 2004). I used most of these strategies while caring for my patient
and while formulating interventions.
Once I determined the patient was in pain I tried using both pharmacological and non-
pharmacological interventions. The pain management system should use a multimodal approach
that includes pharmacological and non-pharmacological interventions (Godfrey, 2005). After
my patient denied pain meds, I decided to take the non-pharmacological approach. There are a
variety of non-pharmacological approaches to managing pain , including physiotherapy, heat
pads or ice packs, massage, relaxation and distraction therapies, hypnotherapy, transcutaneous
electrical nerve stimulation (TENS) and acupuncture (Godfrey, 2005). I implemented heat,
relaxation and distraction therapies while caring for my patient.
This was a great experience because I find myself looking for signs and symptoms of
pain in other patients now. When assessing patients for pain, I keep pain culture in mind and
makes decisions on how to implement these best practice standards into my own practice.
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References
Davidhizar, R., & Giger, J. (2004). A review of the literature on care of clients in pain who are
ggggggculturally diverse. International Nursing Review, 51(1), 47-55.

Godfrey, H. (2005). Pain management. Understanding pain, part 2: pain management. British
ggggggJournal Of Nursing, 14(17), 904-909.

Nworah, U. (2012). From Documentation to the Problem: Controlling Postoperative Pain.
ggggggNursing Forum, 47(2), 91-99. doi:10.1111/j.1744-6198.2012.00262.x