7/29/2019 ncp proper acute pain

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Assessment Explanation of the

Problem

Goals and

Objectives

Interventions Rationale Evaluation

S> “Masakit dito (pointing

to RUQ of abdomen). Para

syang nagagasgas, lalo na

pag gumagalaw ako. Di

naman maiwasang

gumalaw kase madami dinginagawa.” 

O> Vital signs are as

follows: T: 36.5c per

right axilla, BP: 120/80

mmHg per right arm ---o,

RR: 18 cpm, PR: 82 bpm

per left radial pulse, +2;

Pain rated as 7/10

characterized as cramping,

non-radiating, continuous

pain; Seen holding RUQ of 

abdomen noted,

grimacing, weakness

noted, Capillary refill of 1-2

seconds, ultrasound

reveals stone formation

and deposition in the gall

bladder.

A> Acute pain related to

stimulation of the

nerve endings.

Patient came to Emergency

Room from OPD, due to Right

Upper Quadrant pain. The

pain is mainly due to the gall

bladder stones that was

irritating the patient’s

gallbladder. (as revealed bythe Ultrasound). Because of 

the gallbladder stones, the

cell membrane of the

gallbladder starts to be

disrupted. Causing the

release of inflammatory

response to the blood

stream. Chemical mediators

such as Histamine,

Prostaglandin, Bradyikinins,

and Leukotrienes cause the

swelling of the gallbladder.Prostaglandin and

Bradykinins were responsible

for the cramping pain on

RUQ of the abdomen being

felt by the patient. In

addition, cholecystectomy is

indicated for the

management of this disease

problem.

Goal: To deliver maximum

care and treatment to this

client with gall bladder

stones and to relieve from

any kind of discomfort.

LTO: Within 3 days of 

nursing interventions,patient will continuously

manifest relief of pain and

no complaints of any kind of 

discomfort.

STO: After 30 minutes of 

nursing interventions, the

client will manifest a

decrease of pain from 7/10

to 4/10.

: After 5 minutes of nursing education, the client

will be able to do Deep

Breathing Exercises.

: After 10 minutes of 

nursing discussion, the

client will be able to

enumerate as many as

possible stimuli causing

pain.

: After 5 minutes of 

nursing interventions, the

client will be able to assume

comfortable position to

decrease discomfort.

1.  Assess Vital signs.

2.  Assess PQRST of 

pain.

3.  Assess non-verbal

cues of pain.

4.  Assess capillary

refill.

5.  Allow patient toassume

comfortable

position.

6.  Promote rest and

sleep by clustering

interventions.

7.  Instruct to do

Deep Breathing

Exercises.

8.  Advice to do

diversional

activities such as

reading books.

1. Vital signs could be a great trick

to detect patient response to the

condition. BP may aggravate from

intense pain. RR, may came from

intense pain may lead to

hyperventilation,PR compensation

of the body to pain s ensation, T 

may indicate infection or disease

process. 2. Characteristic of pain indicates

what specific organ problem is being

encountered. Can be used to

properly manage the problem. 

3. Non-verbal cues of pain gives you

a clue or hint regarding the pain

status of the client. 

4. Vital signs are affected by pain

sensation thus, PR and RR which

are responsible for proper

oxygenation of the cells. Must be

check to see if proper distribution of 

nutrients and o2 occurs. 

5. Patient knows better her body,

thus, allowing her to assume her

comfortable position may help to

alleviate the pain sensation thus

promoting comfort in patient’s

condition. 

6. Sleep could be a good example of 

diversion activity to relieve pain due

to non-responding to pain sensation

by closing the “gateway” of 

impulses to the brain. In addition,

rest and sleep, rehydrates and

energizes the cells.

7. DBE can help relieve pain by

allowing the release of bête

endorphins which is well known asour natural analgesic. 

8. Diversional activity closes the

“gateway” of pain nerve impulses,

thus it won’t reach the pain center

of the brain producing NO pain

sensation or atleast, drcreased. 

STO: After 30 minutes of nu

interventions, the client able

manifest a decrease of pain

7/10 to 4/10. Fully met 

: After 5 minutes of nurs

education, the client was ab

do Deep Breathing Exercisesmet

: After 10 minutes of nur

discussion, the client was ab

enumerate as many as possi

stimuli causing pain. Fully m

: After 5 minutes of nurs

interventions, the client was

to assume comfortable posit

decrease discomfort. Fully m

LTO: Within 3 days of nursin

interventions, patient will

continuously manifest relief

pain and no complaints of a

kind of discomfort.

* Fully met, if the patient wi

able to verbalize no complai

pain.

** Partially met, if patient

verbalize at least a decrease

pain sensation. Modify

intervention or Continue.

***Unmet, if still the patien

complains of intense pain.

Continue or modify Interven

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