Medical Dx FSCC Clinical Tool: Medical Diagnosis

Student_________________ Clients Initials_______ Clinical Week_______

Pathology of Disease: Describe the pathology related to your patients medical diagnosis. Include textbook signs and symptoms

My patient is experiencing acute, intractable pain of an unknown cause. Acute pain results from acute injury, disease, tissue ischemia,
muscle spasm, or surgery. My patient had deep somatic pain of bone, muscle blood vessels, and connective tissues. Acute pain serves a
biologic purpose, because it acts as a warning signal. It activates the sympathetic nervous system into various physiologic responses such
as: increased heart rate, increased blood pressure, increased respiratory rate, dilated pupils and, sweating. Behavioral signs of acute pain
may include restlessness, an inability to concentrate, apprehension, and overall distress. Acute pain is usually temporary, of sudden onset,
and easily localized. The patient can usually describe the type of pain, and it normally confines itself to a certain area of the body.
Although possibly severe, acute pain is limited over time and generally can be managed successfully. The gate control theory concludes
that there is a strong relationship between behavioral and emotional responses to pain. According to this theory, a gating mechanism
occurs in the spinal cord. Nerve fibers (A delta and C fibers) transmit pain impulses from the periphery of the body traveling to the dorsal
horn of the spinal cord, specifically to the substantia gelatinosa. The cells of the substantia gelatinosa can inhibit or facilitate the pain
impulses transmitted to the trigger (T cells) cells. When T cell activity is inhibited, the gate is closed and impulses are less likely to be
transmitted to the brain. When the gate is opened, pain impulses ascend to the brain. A wide range of sensory input is capable of
producing pain. Signs and symptoms of acute pain include: Verbal or coded report of pain by observed evidence, protective gestures,
guarded behavior, facial mask, sleep disturbances, beaten look, grimace. Self focus or narrowed focus such as altered time perception,
impaired thought processes, reduced interaction with people and environment. Distraction behavior such as pacing, seeking our other
people or activities, repetitive activities. An autonomic change in muscle tone which may span from listless to rigid. Autonomic
physiologic responses to pain such as: diaphoresis, changes in blood pressure, respiration, pulse, and pupillary dilation. Patient may
exhibit expressive behavior such as: restlessness, moaning, crying, vigilance, irritability, and sighing. Often a person in pain has a change
in appetite and eating.

Medical-Surgical Nursing 5th Edition, Ignatious, and Workman

Nursing Care Planning Guides 6th Edition, Ulrich and Canale
Textbook Picture Client Presentation
Signs and Symptoms: Verbal or coded Signs and Symptoms: Patient was moaning, grimacing, rubbing painful area, sweating, and
report of pain by observed evidence, restless. Patient had speech impairment R/T a CVA, and was only able to occasionally state
protective gestures, guarded behavior, not good when asking about the pain.
facial mask, sleep disturbances, beaten
look, grimace. Self focus or narrowed
focus such as altered time perception,
impaired thought processes, reduced
interaction with people and environment.
Distraction behavior such as pacing, Medical Management including medications, diagnostic tests & surgery: The patient was
seeking our other people or activities, taking Morphine 4mg q3-4 hrs PRN, Soma for a muscle relaxant, and Ativan to reduce
repetitive activities. An autonomic change anxiety. Patient had thoracic, lumbosacral, and pelvic x-rays that showed no obvious reasons
in muscle tone which may span from for the intractable pain. Patient also had urinalysis, urine culture, CBC and CMP tests run.
listless to rigid. Autonomic physiologic
responses to pain such as: diaphoresis,
changes in blood pressure, respiration,
pulse, and pupillary dilation. Patient may
exhibit expressive behavior such as:
restlessness, moaning, crying, vigilance, Prognosis: The pain will continue until the physician can find the cause of the problem.
irritability, and sighing. Often a person in
pain has a change in appetite and eating.

Medical Management including

medications, diagnostic tests & surgery:
Prognosis:

Nursing Care Nursing Care

How does your client compare to what is considered usual medical/nursing interventions?