2025 Sample Nursing Paper: Case Study on Post-Surgical Pain

Introduction

Pain management is very important in post-surgical nursing care. Pain relief not only helps in the recovery process but also improves the overall well-being of patients. This paper is a case study of post-surgical pain management of a 45 year old female who had a knee replacement surgery. The nursing interventions implemented, pain assessment, and patient education provided are explored in detail. The goal is to evaluate the efficacy of nursing interventions in managing post-surgical pain and to offer a detailed care plan for patients who will undergo the same procedure.

Case Study Overview

Patient Information

Name: Jane Doe (pseudonym)
Age: 45
Gender: Female
Diagnosis: Knee Osteoarthritis (Unilateral Knee Replacement Surgery)
Surgical Procedure: Unilateral Knee Replacement (UKR)
Date of Surgery: January 10, 2025
Complaint: Severe knee pain due to osteoarthritis.

Medical History: Jane has a history of chronic osteoarthritis that resulted in the need for knee replacement surgery. Additionally, she also suffers from hypertension and obesity. Currently, she is on medications for pain management such as acetaminophen and ibuprofen, and is doing physical therapy following surgery.

Nursing Assessment

The data used for the nursing assessment includes both subjective and objective data. The nursing care plan includes the patient’s self-reported pain levels, vital signs, and physical examination findings.

Subjective Data

Pain Level: The patient describes the pain in the knee area as moderate to severe, and it becomes worse after physical therapy sessions.
Patient’s pain scale: 7/10 after therapy and 4/10 at rest.
Other Symptoms: The patient also reports mild swelling around the surgical site, but no signs of infection (no redness or warmth).

Objective Data

Vital Signs: The patient’s blood pressure is elevated at 140/85 mmHg as a result of the pain and her history of hypertension. Her respiratory rate is 18 breaths per minute, which is normal, and the temperature is 98.6° F. The pulse rate is 92 beats per minute, slightly elevated.
Physical Examination: Knee is swollen with a few areas of bruising which is normal for first 48 hours after surgery. Deep vein thrombosis (DVT) is not present and the patient has full range of motion of the unaffected knee.

Nursing Diagnosis

According to the assessment, the following nursing diagnoses are diagnosed:

Acute Pain: Post-surgical acute pain caused by changes of tissue integrity and inflammation, as the patient reported level of pain (7/10 on pain scale) and presence of swelling around the surgical site.
Risk of Infection: Post-surgical status and swelling indicate risk for Infection related to surgical incision.
Physical Mobility Impaired related to surgical procedure, as evidenced by lack of independent ability to perform activities of daily living (ADLs).
Ineffective Health Management: The patient’s lack of understanding of pain management techniques and post-surgical care was evidenced by ineffective Health Management due to the patient’s anxiety about managing pain at home.

Pain Management Interventions

The main aim for this patient is to manage pain effectively so that recovery is promoted, complications are prevented, and the patient’s quality of life is improved. Pharmacological and non-pharmacological strategies are the nursing interventions.

Pharmacological Interventions

The patient is given acetaminophen 500 mg every 6 hours for pain relief as it is effective for mild to moderate pain.
Oxycodone 5 mg every 4–6 hours for breakthrough pain is also prescribed for the patient, to be used during physical therapy or when the pain is above baseline.
Additional pain relief is given to the patient by ibuprofen 400 mg every 8 hours for inflammation and pain.
Nursing staff monitors the patient’s response to pain medications, looking at any adverse effects from the medications like dizziness, nausea, or sedation. The nurse also makes sure that the patient is not dependent on opioids in any way and that the lowest effective dose is used.

Non-Pharmacological Interventions

Ice Therapy: Ice applied for 20 minutes per hour post-surgery is highly effective in reducing swelling and giving you relief from pain.
Positioning: The leg being raised up on a pillow is while being elevated to promote venous return and reduce the swelling in the leg.
Relaxation Techniques: Deep breathing and guided imagery are relaxation techniques that teach the patient deep breathing exercises and guided imagery to promote relaxation and reduce anxiety.
Physical Therapy: Also encourages early mobilization and assisting the patient with gentle range of motion exercises to prevent joint stiffness and improve circulation.

Patient Education

Pain Management: The nurse teaches the patient about the significance of following the pain management plan as described by the doctor: taking the medications in the exact time and in the correct manner.
Signs of Infection: The patient is given instructions to inform the physician if the patient has signs and symptoms of infection, as evidenced by increased redness, warmth, and fever.
Post-Surgical Care: The nurse talks about how to take care of the surgical site after the surgery: cleaning techniques and why the area should remain dry.
Weight Bearing Restrictions: The patient is told what weight bearing restrictions they will have and how to return to normal activities but without straining their knee.

Evaluation of Pain Management Effectiveness

Continuous evaluations of pain levels and patient’s physical and emotional responses with regard to the pain management interventions are done regularly in order to determine their effectiveness.

Post-Intervention Assessment

Pain Level: The patient states that after implementing pain management interventions, the patient’s pain level is 4/10 during physical therapy and 2/10 at rest. This means that the pain control is much improved.
Vital Signs: Blood pressure is 130/80 mmHg, indicating that the individual is better in terms of pain control and also at reducing stress on their cardiovascular system. Pain medications are not causing adverse effects as pulse and respiratory rate remains stable.
Mobility: The patient can assist with range of motion exercises with less pain, and shows improved mobility and physical function.
Patient Education Feedback: The patient will verbalize understanding of the importance of following the prescribed pain management plan and postoperative surgical incision care instructions.

Revised Nursing Diagnosis

Acute Pain – The patient’s pain is now under control (2/10 when at rest) and the nursing interventions are thought to be effective.
Risk for Infection: If the surgical site remains clean with no signs of infection, it means that the education and post-surgical care plan was effective.
Impaired Physical Mobility: The patient’s physical mobility has improved and she can participate in physical therapy with assistance.
Inefficient Health Management: The patient is now able to understand the pain management and postoperative care, thus minimizing complications.

Conclusion

The critical aspects of this nurse sensitive intervention management to post-surgical pain are highlighted by this case study. Nurses can greatly reduce the pain levels of patients, facilitate the recovery of patients, and prevent complications by using a combination of pharmacological and nonpharmacological strategies. Assessment, education, and support must be continued in order to ensure the patient achieves the best possible outcome. Nursing professionals’ implementation of a comprehensive care plan that involves pain management, patient education, and physical rehabilitation helps to improve the patient’s health and well-being.

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Breakdown of Structure

Introduction

Brief introduction to the case study topic (pain management in post-surgical patients).
Patient details and surgical procedure are introduced.
Objective of the paper.

Case Study Overview

Patient information (age, gender, diagnosis, etc.).
Relevant medical history and the reason for surgery.
Description of the patient’s current condition post-surgery.

Nursing Assessment

Subjective data: Pain levels and other symptoms reported by the patient.
Objective data: Vital signs and physical exam results.
Nursing Diagnosis: It is the process of identifying the key nursing diagnoses from the assessment.

Pain Management Interventions

Pharmacological: Pain medications, prescribed and rationale.
Other: Non–pharmacological (ice, positioning, relaxation).
Patient Education: The educating of the patient in terms of pain management, infection prevention and recovery.

Evaluation of Pain Management Effectiveness

Pain levels, vital sign, mobility, and patient feedback post-intervention.
Reassessment of nursing diagnoses and their resolution.

Conclusion

Summary of the case study.
Reflection on the effectiveness of nursing interventions.