NCP- Acute Pain.docx

7/27/2019 NCP- Acute Pain.docx

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Assessment Nursing

Diagnosis

Rationale Desired Outcome Nursing Intervention Justification Evaluation

Actual Abnormal

Cues:

Patientverbalized Gasakit akun mata,ga hapdi kag daw

may ma guwa

Pain Scale of 7out of 10

(moderate tosevere pain)

Tenderness,swelling and

redness of theright eye

Feeling ofwarmth

under the eyesupon palpation

Facial mask-grimacing andcrying

Exhibitedguardingbehavior of the

Acute Pain

related totissue injury of

the eye

secondary tomechanicaltraumaas

evidenced by

inflammatory

process, facialgrimacing, and

guardingbehavior

Definition:

Unpleasant

sensory andemotionalexperience

arising fromactual or

potential tissuedamage or

described interms of such

damage(International

Association for

the Study ofPain); suddenor slow onset

Mechanical trauma

penetrating the orbital areacausing tissue inflammation

Release of pain andinflammatory mediators

After 8 hours of

nursing interventionthe patient will be able

to:

1.Follow prescribedpharmacological

regimen

2.Demonstrate use of

relaxation skills anddiversional activitiesas indicated for

individual situation

Independent and

Collaborative

Interventions:

-Administer analgesics asindicated such as

Paracetamol 200mg/IVTT/ Q4

-Monitor vital signs

-Teach the use of

nonpharmacologictechniques (e.g.relaxation,

guided imagery, musictherapy, distraction, and

massage) before,after, and if possible

during painful activities;before pain occurs or

increases; and along withother pain relief

measures.

-To maintainacceptable level

of pain

-Usually altered

in acute pain

-The use of

noninvasive painrelief measurescan increase the

releaseof endorphins and

enhance thetherapeutic

effects of painrelief

medications.

After 8 hours of nursing

intervention the patient was ato:

1.Goal met. Demonstrated gcompliance to prescribed

medication by taking it at theright schedule.

2. Goal partially met. Activ

participates in the relaxationtechniques lead by the studennurse as well as in other play

activities prepared based on pdevelopmental stage.

Predisposing

Factors:

Unknown/unidentified foreign

object entered the

eye causing irritation

Precipitating

Factors:

Lifestyle Attitude Parental

Guidance

Age=12 (tendto be active)

Gender- Male


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affected eyewhen being

inspected

Elevated WBClevel of 17.7

(normal is 4.5 to13.5) 10^9/L

Strengths:

Good familysupport

Good complianceto treatment

regimen

of any intensityfrom mild to

severe with ananticipated or

predictable endand a duration

of less than 6months

Source:

Doenges, M.E,

et. Al. Nurses

Pocket GuideEdition 11.

F.A. DavisCompany.

Philadelphia,Pennsylvania.

2008.

(bradykinin, prostaglandin)

Nociceptors send signals to

the brain of the intensity ofthe pain by increasing the

frequency of signals sent tospecialized areas within the

CNS

Pain signals travel through

the spinal cord into thedorsal horn

Pain signals are sent up, A-

delta nociceptor and C-nociceptor fibers in the

ascending pathways to thebrain

facial mask, grimace,

feeling of warmth in theeye, tenderness, guarding

behavior, increase vitalsigns

Acute Pain

Source:Atlas ofPathophysiology, 3

rdEd.

Lippincott

3.Verbalize methodsthat provide relief

4.Show a positive

behavior in the reliefof present condition

-Provide comfortmeasures such as change

in position, use of heat orcold compress to the

affected site

-Assess level of pain asof the moment

-Instruct or encourageuse of relaxation

exercises, such asfocused breathing

-Encourage adequate restperiods

-Evaluate the

effectiveness of the paincontrol measures used

thorough ongoingassessment of pain

experience.

-to provide nonpharmacological

pain management

-to provide duecare in alleviating

the suffering ofthe patient

-to assist client toexplore methods

for alleviation/control of pain

-to preventfatigue

-Research shows

that the mostcommon reason

for unrelievedpain is failure to

routinely assesspain and pain

relief. Many

3. Goal partially met.Verbalizes specific positions

such as lying down in supineposition and procedures that

alleviates pain such as playactivity and provides relief

through medicationadministration.

5. Goal partially met.Demonstrated positive behavtowards present condition by

participating in the treatmentregimen provided for him.


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-Perform acomprehensive

assessment of pain toinclude location,

characteristics,onset/duration,

frequency, quality,severity, and

precipitating oraggravating factors

clients silentlytolerate pain if

not specificallyasked about it.

-Pain is asubjective

experience andmust be described

by theclient in order to

plan effectivetreatment to

assessprecipitating

contributoryfactors

Documents

NCP- Acute Pain.docx