Welcome to Scribd, the world's digital library. Read, publish, and share books and documents. See more
Download
Standard view
Full view
of .
Look up keyword
Like this
285Activity
0 of .
Results for:
No results containing your search query
P. 1
Ncp acute Pain

Ncp acute Pain

Ratings:

4.38

(8)
|Views: 45,891|Likes:
Published by Aimee Ann Macaraeg

More info:

Categories:Types, School Work
Published by: Aimee Ann Macaraeg on Feb 08, 2009
Copyright:Attribution Non-commercial

Availability:

Read on Scribd mobile: iPhone, iPad and Android.
download as DOC or read online from Scribd
See more
See less

03/05/2014

 
CUES NURSINGDIAGNOSISINFERENCES PLANNING NURSINGINTERVENTIONSRATIONALE EVALUATIONSUBJECTIVE:
-Patientverbalized“Masakityung tuhodko, yung parte namaynakatusok,”-Verbalized“Namamanhid yungtuhod ko, parang maytumutusok, pasumpong-sumpongsya.”-Verbalized“Masmasakityungrayuma kosa kaliwangkamay, pasumpong-sumpongsya.”-Verbalized“MasakitAcute painrelated to physicalagent andinflammatory processsecondary toinsertion of Steinmann pin and presence of arthritisrespectivelyUnrelievedacute pain leadsto debilitation,diminishedquality of life,and depression.Unrelievedacute postoperative pain leads todevelopment of chronic painsyndromes andincreasedcomplications.In fact,unrelieved paincan kill.
Source:Medical-Surgical  Nursing, 7 
th
ed.by Black, JoyceM. and Jane Hokanson Hawks; p. 440
GOAL:
After 8 hours of nursinginterventions, the patient will beable to experiencegradualreduction/relief of  pain.
OBJECTIVES:
After the series of nursinginterventions, the patient will beable to:1. verbalizereduction/relief of pain.2. have normalRespiratoryRate.3. move his leftupper extremitywithout facialgrimace
INDEPENDENT:
1. Instruct client toreport anyimprovement/exacer-bation in painexperience.2. Encourageverbalization of feelings about the pain.
INDEPENDENT:
1. Unrelieved paincan create other  problems such asanger, anxiety,immobility,respiratory problems, anddelay in healing.(
Medical-Surgical  Nursing, 7 
th
ed. by Black, Joyce M.and Jane Hokanson Hawks; p. 443)
 2. Only the client can judge the level anddistress of pain; pain managementshould be a teamapproach thatincludes the client.Very few people lieabout pain.(
Medical-Surgical  Nursing, 7 
th
ed. by Black, Joyce M.and Jane Hokanson Hawks;
EFFECTIVENESS:
Was the patient able toexperience gradualreduction/relief of painafter 8 hours of nursinginterventions? __yes __nowhy?Was the patient able toverbalize reduction/relief of pain after the series of nursing interventions? __yes __nowhy?Was the patient able tohave normal respiratoryrate after the series of nursing interventions?? __yes __nowhy?Was the patient able tomove his left upper extremity without facialgrimace after the seriesof nursing interventions? __yes __nowhy?
 
yungrayuma kolalo na pagginagalawko; lagisyangkumikirot.”
OBJECTIVE:
-Pain scaleof 10 for arthritis onleft wrist-Pain scaleof 2 for siteof Steinmann pininsertion-RR: 21cpm-Exhibitedfacialgrimaceuponmovementof the leftupper extremity-Exhibitedfacialgrimaceupon
 Etiology of  Acute Pain from the Siteof Steinmann Pin Insertion:
Immediatecause:
Activation of nociceptors or  pain receptors
Intermediatecause:
Break in theskin integrity
Root cause:
Insertion of Steinmann pin
 Etiology of  Pain on Left Wrist:
Immediatecause:
Activation of nociceptors or  pain receptors
Intermediatecause:
4. have no facialgrimace upon palpation of the wrist5. recite thenonpharmacologic ways tolessen pain.6. demonstratethenonpharmacologic ways tolessen pain.3. Provide comfortmeasures such asuse of incentivespirometry or blow bottles.4. Encouragerelatives to perform touchtherapy.5. Encourage andassist client to dodeep breathingexercises.
 p. 443)
3. To providenonpharmacologic pain management.
(Nurse’s Pocket Guide, 9
th
ed. by Doenges,Marilynn, et.al., p.368)
4. The human bodyis believed to haveenergy fields thatexpress aberrant patterns when bodysystems areinsulted.Therapeutic Touchis thought torealign aberrantfields. (
Medical-Surgical Nursing,
th
ed. by Black, Joyce M. and Jane Hokanson Hawks; p. 480)
 5. Deep breathing for relaxation is easyto learn andcontributes to painrelief and/or Was the patient able tohave no facial grimaceupon palpation of thewrist after the series of nursing interventions? __yes __nowhy?Was the patient able torecite thenonpharmacologic waysto lessen pain after theseries of nursinginterventions? __yes __nowhy?Was the patient able todemonstrate thenonpharmacologic waysto lessen pain after theseries of nursinginterventions? __yes __nowhy?
EFFICIENCY:
Were the humanresources, materials andtime used economically? __yes __nowhy?
 
 palpationof the wristInflammatory process
Root cause:
Presence of anunderlyingdisease/condition(Rheumatoidand Goutyarthritis)6. Provide psychologicalsupport/motivation.7.Encouragemobilization of theleft upper extremity. Assistwith ROMexercises.8.Encourageadequate periodsreduction byreducing muscletension andanxiety. (
Medical-Surgical Nursing,
th
ed. by Black, Joyce M. and Jane Hokanson Hawks; p. 479)
 6. If the client is ill,ascertain themotivation for returning to anoptimal level of wellness.(
Medical-Surgical  Nursing, 7 
th
ed. by Black, Joyce M.and Jane Hokanson Hawks; p. 75)
 7.To promotecirculation and prevent excessivetissue pressure.(
 Fundamentals of  Nursing 7 
th
ed.by Kozier, Barbara, p.535)
8.To prevent fatigue.
(Nurse’s Pocket 
APPROPRIATENESS:
Were the interventionssuitable to client’ssituation? __yes __nowhy?Were the setting andtime table interventionsrealistic to client’ssituation? __yes __nowhy?
ACCEPTABILITY:
Were the interventionsaccepted by the patient(without any signs of rejection from the patientand family members)? __yes __nowhy?
ADEQUACY:
Was the number of interventions sufficientto meet the desired goaland objectives? __yes __nowhy?

You're Reading a Free Preview

Download
scribd
/*********** DO NOT ALTER ANYTHING BELOW THIS LINE ! ************/ var s_code=s.t();if(s_code)document.write(s_code)//-->