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Case Study: Darren

The nursing problem is potential for pain related to surgical incision as evidenced by grimacing and a subjective pain score of > 3/10 using the Numeric Pain Rating Scale.

This nursing problem is important because the patient Darren has just come out of the surgical room to the ward and on grimacing and subjective assessment of pain, his pain level was more than 3/10 on Numeric Pain Rating Scale. This indicates that the patient is in pain due to the surgical incision. In the first four hours of his return to the surgical ward, he is at high risk of the development of pain because the pain in the incision and abdomen is common after the surgical procedure. The pain due to incision in Darren is associated with his comorbidities. The data and documentation of Darren reveals that he is obese having BMI 33. The obese patients who undergo surgery are at highest risk of developing complications in the post- operative stage because of the wound complications.

The pain at the site of incision is related to the surgical wound. The three major body systems such as cardiovascular system, respiratory system and hepatics have major impact on would healing (Bhalla, 2019).The medical history of Darren states that he had many systemic diseases like hypertension, hyperlipidemia that are all associated to obesity. Obesity has a direct impact on the cardiovascular system of the patient as it increases the work load of the heart. The heart is overloaded with the work of supplying oxygenated blood to all the tissues and to remove the waste material. Therefore, good circulation system is very important for wound healing. The circulatory system supplies the white blood cells, fibrocytes and nutrients that are important for the process of wound healing. Due to the effect of long- standing obesity, the heart fails because of the overload that eventually decreases the cardiac output and blood volume (Pierpont et al., 2014).

This results in the impaired circulation to the surgical wound. This results in inappropriate wound healing thus high risk of pain. The patient Darren is at high risk of pain especially within the first four hours of surgery because the wound healing starts after the incision is made and due to the obesity, the circulation system fails at healing the wound appropriately. The patient has been smoking 30 cigarettes per day over last 20 years and is a social drinker that adds up to his weak cardiovascular system.

The inappropriate healing that increases the risk of pain may also be caused due to the layers of skin that does not hold sutures tight together thus they loosen up causing inappropriate healing (Ryu et al., 2019). Darren is at increased risk of developing pain due to wound complications in the first four hours of surgery thus requires proper nursing management of the wound and management of the vital signs. The cardiovascular issues like hypertension, high cholesterol levels (comorbidities) are all associated with obesity that is further associated with the development of complications in the post- operative phase.

Patient centered SMART goal is to reduce the pain in the surgical incision so that the patient is comfortable by the end of the day.

The first intervention for this SMART goal is to administer morphine for pain management as per the prescription of the doctor. The rationale for this intervention is that morphine is the first choice of opioid to be used for pain management because opioids binds to the receptors in the central nervous system and peripheral tissues to modulate the effect of nociceptors (Lalmand et al., 2017). The most common intravenous opioid used for post- operative pain management is morphine and this will be administered by the nurse through IV route of administration.

The nursing consideration will be the dose of the medication and carrying out physical pain assessment in the patient after four hours of the medication administration. The patient will be given this medication along with others that will help in managing the painful condition and the consequence would be that patient would get comfortable after some time due to reduced pain levels (Kayhan et al., 2019). Thus this intervention is suitable to be applied for SMART goal.

The second intervention for this SMART goal is to facilitate correct positioning technique for the patient so that he can be made to feel comfortable. The surgery incision pain is around the area of incision and positioning plays a very important role in making the patient comfortable or uncomfortable (Mohan & Winter, 2017). The patient has an incision and he has pain around that area so the positioning technique suitable for him would be that he is made to use pillows during the sleep. This would prevent the patient on sleeping his back and the positioning of the patient is also very important during dressing change as it is positively associated with the decrease in incision related pain. The correct positioning technique will help the patient in managing pain also as the incision site will not be pressured due to wrong position (Giambartolomei et al., 2018). This intervention is effective and can be evaluated by assessing the patient for his pain levels and also feedback can be taken if he is comfortable or not.

The third intervention for this SMART goal is to provide the patient with counselling sessions because management of psychological wellbeing is also important. The patient will be given counselling session in which the nurse will talk to the patient and cognitive behavioural therapy his feelings can be better understood. The nurse will address the pain of the patient using this holistic approach (Joudi et al., 2016). This intervention is highly effective as post- operative pain can cause significant negative impact on mental health and the patient also has medical history of mild depression. Thus this intervention will prove to be highly effective for Darren. Other psychological approaches like cognitive behavioural therapy (CBT) is also effective in managing the mental health of the patient as the nurses perform these techniques showing empathy to the patients (Jin et al., 2019). CBT based psychological interventions decreases the post- surgical pain intensity and disability in the patients.

The above mentioned three interventions for the use for post- operative pain management will help in achieving the SMART goal and this will help the patient in faster recovery. The evidence based assessments that can be used to evaluate the effectiveness of the implemented nursing interventions. The nursing intervention of administration of morphine (pain managing medication) can be evaluated using a pain score scale and grimacing in which the lowered pain levels can be considered as the effectiveness of the intervention (Hatherley, Jennings & Cross, 2016). The second intervention for the pain management and providing physical comfort to the patient is application of appropriate position techniques.

This intervention can be evaluated for its effectiveness using the patient’s feedback. The patient’s feedback will help in learning that the patient is comfortable with the reduced pain and comfortable position that is not applying strain on the wound (Janse et al., 2017). This assessment of the intervention of positioning technique will help the nurse in learning the effectiveness of the intervention otherwise the nurse may change this intervention if it is not helping Darren. The patient Darren had history of mild depression and the nurse would take care of the patient using holistic approach.

For this the third intervention of cognitive behavioral therapy and talk therapy will be applied and this intervention can be best assessed using the Geriatric Depression Scale (GDS) (Durmaz et al., 2018). This assessment tool is an effective tool for the use among geriatric patients for screening depression among the patients and after the application of intervention, this assessment tool can be used. The lower values of depression in Darren tested using the Geriatric Depression Scale (GDS) will prove the efficacy of this intervention (Merkin et al., 2020).

The overall improved health and reduced pain at the surgical incision will prove the effectiveness of these interventions. The physical and mental comfort will also reveals the effectiveness of these interventions.


Bhalla, P. (2019). Effect of obesity on the wound healing process. Retrieved from https://digitalcommons.imsa.edu/sir_presentations/2019/session1/40/

Durmaz, B., Soysal, P., Ellidokuz, H., & Isik, A. T. (2018). Validity and reliability of geriatric depression scale-15 (short form) in Turkish older adults. Northern Clinics of Istanbul, 5(3), 216.

Giambartolomei, G., Szomstein, S., Rosenthal, R., & Menzo, E. L. (2018). Fundamentals of patient positioning and skin prep. In Fundamentals of General Surgery (pp. 65-82). Switzerland: Springer, Cham.

Hatherley, C., Jennings, N., & Cross, R. (2016). Time to analgesia and pain score documentation best practice standards for the Emergency Department–A literature review. Australasian Emergency Nursing Journal, 19(1), 26-36.

Janse, P. D., De Jong, K., Van Dijk, M. K., Hutschemaekers, G. J., & Verbraak, M. J. (2017). Improving the efficiency of cognitive-behavioural therapy by using formal client feedback. Psychotherapy Research, 27(5), 525-538.

Jin, Y., Zhang, J., Zheng, M. C., Bu, X. Q., & Zhang, J. E. (2019). Psychosocial behaviour reactions, psychosocial needs, anxiety and depression among patients with rectal cancer before and after colostomy surgery: A longitudinal study. Journal of Clinical Nursing, 28(19-20), 3547-3555.

Joudi, M., Fathi, M., Izanloo, A., Montazeri, O., & Jangjoo, A. (2016). An evaluation of the effect of hypnosis on postoperative analgesia following laparoscopic cholecystectomy. International Journal of Clinical and Experimental Hypnosis, 64(3), 365-372.

Kayhan, O., Akçıl, E. F., Dilmen, Ö. K., & Tunalı, Y. (2019). The effects of locally administered morphine over the dura on postoperative morphine consumption and pain after lumbar disc surgery: A prospective, randomised, double-blind and placebo-controlled study. Turkish Journal of Anaesthesiology and Reanimation, 47(4), 301.

Lalmand, M., Wilwerth, M., Fils, J. F., & Van der Linden, P. (2017). Continuous ropivacaine subfascial wound infusion compared with intrathecal morphine for postcesarean analgesia: a prospective, randomized controlled, double-blind study. Anesthesia & Analgesia, 125(3), 907-912.

Merkin, A. G., Medvedev, O. N., Sachdev, P. S., Tippett, L., Krishnamurthi, R., Mahon, S., ... & Doborjeh, M. G. (2020). New avenue for the geriatric depression scale: Rasch

transformation enhances reliability of assessment. Journal of Affective Disorders, 264, 7-14.

Mohan, H., & Winter, D. (2017). Minor surgery at a glance. John Wiley & Sons.

Pierpont, Y. N., Dinh, T. P., Salas, R. E., Johnson, E. L., Wright, T. G., Robson, M. C., & Payne, W. G. (2014). Obesity and surgical wound healing: A current review. ISRN Obesity, 2014.

Ryu, J., Loza, C. A., Xu, H., Zhou, M., Hadley, J. T., Wu, J., ... & Liu, F. (2019). Potential roles of adiponectin isoforms in human obesity with delayed wound healing. Cells, 8(10), 1134.

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