Question

During the administration of a warm tap-water enema, a patient complains of cramping abdominal pain that he rates 6 out of \(10 .\) What nursing intervention should the nurse do first? a. Stop the instillation. b. Ask the patient to take deep breaths to decrease the pain. c. Tell the patient to bear down as he would when having a bowel movement. d. Continue the instillation; then administer a pain medication.

Short answer

The nurse should first stop the instillation to address and prevent worsening of the patient's abdominal cramping.

Step-by-step solution

Identify the patient's complaint

Recognize that the patient is experiencing cramping abdominal pain during the procedure, which needs immediate attention.

Assess the severity of the pain

Acknowledge the patient's pain by considering the rating of 6 out of 10, indicating moderate to severe discomfort.

Determine the best immediate action

Evaluate the options given and determine which one immediately addresses the patient's discomfort and is safe.

Choose the most appropriate intervention

Select option a. Stop the instillation. This action takes priority since it might be causing the discomfort and could prevent further pain or complications.

Key concepts

Pain Management in Nursing

Proper pain management in nursing is pivotal for promoting patient well-being and can significantly influence the healing process. When a patient experiences pain, as with the abdominal cramping during an enema procedure rated at 6 out of 10, the nurse should prioritize evaluating and alleviating that pain.

In the given scenario, the initiation of stopping the enema instillation is a critical step. By doing so, the nurse addresses the likely cause of the discomfort. It is then advisable to further comfort the patient by suggesting deep breaths, which can act as a non-pharmacological pain relief strategy, offering relaxation and potentially reducing the perception of pain.

If pain persists or recurs, nurses may consider other interventions, including the administration of pain medications as prescribed, while always monitoring for potential side effects. In all cases, nursing strategies should focus on a holistic approach, combining pharmacological and non-pharmacological methods, tailored to each patient's individual needs and responses.

Patient Comfort During Procedures

Patient comfort is crucial during medical procedures to minimize anxiety and ensure cooperation, yielding better outcomes. The nurse's role extends beyond mere execution of medical interventions to encompass patient-centered care that prioritizes comfort and ease.

During uncomfortable procedures such as administering an enema, nurses can employ various techniques to increase comfort. Encouraging the patient to take deep, slow breaths can help with relaxation. Providing clear instructions and explaining what to expect during the procedure can also alleviate anxiety.

Moreover, creating a supportive environment by using a gentle tone and offering reassurances can help build trust and make the patient feel cared for. Positioning the patient appropriately and ensuring privacy are additional considerations that contribute to a more comfortable experience.

Assessment of Patient Symptoms

Assessment of patient symptoms is a continuous and dynamic process that underpins effective nursing care. When a patient reports a symptom, such as the abdominal pain described in the exercise, it is important for the nurse to carry out a prompt and thorough assessment.

This includes identifying the nature, location, and severity of the pain. Using a pain scale, like the 0-10 scale in the scenario, is a helpful tool to quantify the patient’s pain. The nurse's assessment would continue by observing for non-verbal cues, such as facial expressions or guarding behavior, which can provide additional insights into the patient’s experience.

By understanding the complete picture of the patient's symptoms, the nurse can make informed decisions about interventions to alleviate the discomfort. Consistent reassessment is necessary after an intervention to evaluate its effectiveness and to make any needed adjustments.