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Saturday, November 27, 2010

NCP- PAIN (CLICK HERE!!!)





Cues
Nursing Diagnosis
Goals and Objectives
Nursing interventions
Rationale
Evaluation
Subjective:

- Patient verbalized: “Sumasakit dito ko (referring to abdomen), parang may naninigas sa loob…dati pa to eh, medyo bata bata pa ko.”

Objective:
-Pain scale of 6 for abdominal pains.
- Exhibits facial grimace upon palpation of the abdomen.
-Shows signs of  Irritability
- Restlessness

Vital Signs:
BP – 120/80
PR – 87 bpm
RR – 32 breaths/min
Temp – 37.4

Chronic pain related to abdominal cramps secondary to non-ulcer dyspepsia
Long Term:
After 3 days of nursing intervention the patient will be
able to experience
gradual reduction / relief of pain from a pain scale of 6 to at least 3.


Short Term:
After series of
nursing
interventions, the
patient will be
able to:
- Verbalize
reduction/
relief of pain in the abdomen.
- Feel and palpate abdomen
without facial
grimace and moaning.
       - Recite and demonstrate some
non-pharmacologic ways to lessen pain.
Independent:
-Provide comfort measures such as use of pillows under extremities and periodic wound cleaning on affected area.
- Encourage and assist client to do deep breathing exercises.
- Teach client and significant other about the non-pharmacologic ways to lessen the pain.
- Instruct client to report any improvement/exacerbation in pain experience.
- Encourage verbalization of feelings about the pain.
- Physical Examination: Periodic auscultation of the abdomen for bowel sounds
Inspection and Palpation for masses and tenderness.

Dependent:
- Administer medications, particularly analgesics, as prescribed.
- Assist with
laboratory/diagnostic studies as indicated. (e.g., abdominal X-ray)

To promote relief and wellness.

Deep breathing exercises contribute to relief of pain

To maximize opportunities for self-control over pain manifestations.

Only the client can
judge the level and
distress of pain;
pain management
should be a team
approach that
includes the client.

Necessary for management of underlying and possible complications.




Cues
Nursing Diagnosis
Goals and Objectives
Nursing interventions
Rationale
Evaluation
Subjective:

- Patient verbalized: “Ang sakit nun (pointing to left lower leg)... kumikirot!”

Objective:
- Pain scale of 8 for pain felt at the left lower leg.
- Exhibits facial grimace and moaning upon movement of  the left lower leg.
-Shows signs of  Irritability
- Restlessness
-Physical immobility

Vital Signs:
BP – 120/80
PR – 87 bpm
RR – 32 breaths/min
Temp – 37.4

Acute pain related to immobility / improper positioning
Long Term:
After 8 hours of
nursing interventions, the
patient will be
able to experience
gradual reduction / relief of pain from a pain scale of 8 to at least 4.

Short Term:
After series of
nursing
interventions, the
patient will be
able to:
- Verbalize
reduction/
relief of pain.
- Move her left
lower
extremity
without facial
grimace
       - Recite and demonstrate some
non-pharmacologic ways to lessen pain.
- Have normal
respiratory rate.
Independent:
- Provide comfort measures such as use of pillows under extremities and periodic wound cleaning on affected area.
- Encourage and assist client to do deep breathing exercises.
- Encourage mobilization of the left lower extremity. Assist with ROM exercises.
- Discuss with client and relatives the importance of proper positioning and mobilization.
- Teach client and significant other about the non-pharmacologic ways to lessen the pain.
- Instruct client to report any improvement/exacerbation in pain experience.
- Encourage verbalization of feelings about the pain.

Dependent:
- Administer medications, particularly analgesics, as prescribed.


To promote relief and wellness.


Deep breathing exercises contribute to relief of pain


To promote circulation and prevent excessive tissue pressure


To maximize opportunities for self-control over pain manifestations.

 Only the client can
judge the level and
distress of pain;
pain management
should be a team
approach that
includes the client.




Cues
Nursing Diagnosis
Goals and Objectives
Nursing interventions
Rationale
Evaluation
Objective:
- Restlessness
- Irritability
-Presence of edema on lower extremities
-Taut, shiny skin on lower extremities
-Fluid intake greater than output

Vital Signs:
BP – 120/80
PR – 87 bpm
RR – 32 breaths/min
Temp – 37.4



Excess Fluid Volume related to impaired venous return secondary to immobility
Long Term:
After 3 days of nursing intervention, the patient will exhibit decreased edema on lower extremities and stabilize fluid volume I&O.

Short Term:
After 8 hours of nursing intervention, the patient will be able to:
-Identify causative factors affecting fluid retention.
-Identify dietary intake and habits that contribute to fluid retention.

Independent:
-Assist in periodic positioning every 2 hours.
-Monitor I&O and amount of fluid intake from all sources and calculate fluid volume imbalance.
- Periodically wash between skinfolds and dry carefully.
-Protect edematous extremities from injury.
-Relate causative factors affecting fluid retention.
- Teach client and relatives about importance of proper positioning and keeping edematous feet elevated and clean.

Dependent:
- Administer Medications.

To prevent pressure ulcers

To monitor kidney function and fluid retention

To prevent injury and promote wellness

To impart knowledge regarding present condition

To promote circulation and prevent excessive tissue pressure



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