CUES SUBJECTIVE: - Patient verbalized “Masakit yung tuhod ko, yung parte na may nakatusok,” - Verbalized “Namaman hid yung

tuhod ko, parang may tumutusok, pasumpong -sumpong sya.” - Verbalized “Mas masakit yung rayuma ko sa kaliwang kamay, pasumpong -sumpong sya.” - Verbalized “Masakit

NURSING INFERENCES DIAGNOSIS Acute pain related to physical agent and inflammatory process secondary to insertion of Steinmann pin and presence of arthritis respectively Unrelieved acute pain leads to debilitation, diminished quality of life, and depression. Unrelieved acute postoperative pain leads to development of chronic pain syndromes and increased complications. In fact, unrelieved pain can kill.

PLANNING GOAL: After 8 hours of nursing interventions, the patient will be able to experience gradual reduction/relief of pain. OBJECTIVES: After the series of nursing interventions, the patient will be able to:

NURSING INTERVENTIONS INDEPENDENT: 1. Instruct client to report any improvement/exac er-bation in pain experience.

RATIONALE INDEPENDENT: 1. Unrelieved pain can create other problems such as anger, anxiety, immobility, respiratory problems, and delay in healing. (Medical-Surgical Nursing, 7th ed. by Black, Joyce M. and Jane Hokanson Hawks; p. 443) 2. Only the client can judge the level and distress of pain; pain management should be a team approach that includes the client. Very few people lie about pain. (Medical-Surgical Nursing, 7th ed. by Black, Joyce M. and Jane Hokanson Hawks;

EVALUATION EFFECTIVENESS: Was the patient able to experience gradual reduction/relief of pain after 8 hours of nursing interventions? __yes __no why? Was the patient able to verbalize reduction/relief of pain after the series of nursing interventions? __yes __no why? Was the patient able to have normal respiratory rate after the series of nursing interventions?? __yes __no why? Was the patient able to move his left upper extremity without facial grimace after the series of nursing interventions? __yes __no why?

2. 1. verbalize reduction/ relief of pain.

Source: MedicalSurgical 2. have normal th Nursing, 7 ed. Respiratory by Black, Joyce Rate. M. and Jane Hokanson 3. move his left Hawks; p. 440 upper extremity without facial grimace

Encourage verbalization of feelings about the pain.

yung rayuma ko lalo na pag ginagalaw ko; lagi syang kumikirot.” OBJECTIVE: - Pain scale of 10 for arthritis on left wrist - Pain scale of 2 for site of Steinmann pin insertion - RR: 21 cpm - Exhibited facial grimace upon movement of the left upper extremity - Exhibited facial grimace upon

Etiology of Acute Pain from the Site of Steinmann Pin Insertion: Immediate cause: Activation of nociceptors or pain receptors Intermediate cause: Break in the skin integrity Root cause: Insertion of Steinmann pin Etiology of Pain on Left Wrist: Immediate cause: Activation of nociceptors or pain receptors Intermediate cause:

p. 443) 4. have no facial grimace upon palpation of the wrist recite the nonpharmacol ogic ways to lessen pain. demonstrate the nonpharmacol ogic ways to lessen pain. 4. 3. Provide comfort 3. To provide measures such as nonpharmacologic use of incentive pain management. spirometry or blow (Nurse’s Pocket bottles. Guide, 9th ed. by Doenges, Marilynn, et.al., p. 368) Encourage relatives to perform touch therapy. Was the patient able to have no facial grimace upon palpation of the wrist after the series of nursing interventions? __yes __no why?

5.

6.

5.

Encourage and assist client to do deep breathing exercises.

Was the patient able to recite the 4. The human body nonpharmacologic ways is believed to have to lessen pain after the energy fields that series of nursing express aberrant interventions? patterns when body __yes __no systems are why? insulted. Therapeutic Touch Was the patient able to is thought to demonstrate the realign aberrant nonpharmacologic ways fields. (Medicalto lessen pain after the Surgical Nursing, series of nursing th 7 ed. by Black, interventions? Joyce M. and Jane __yes __no Hokanson Hawks; why? p. 480) EFFICIENCY: 5. Deep breathing for Were the human relaxation is easy resources, materials and to learn and time used economically? contributes to pain __yes __no relief and/or why?

palpation of the wrist

Inflammatory process Root cause: Presence of an underlying disease/ condition (Rheumatoid and Gouty arthritis)

reduction by reducing muscle tension and anxiety. (MedicalSurgical Nursing, 7th ed. by Black, Joyce M. and Jane Hokanson Hawks; p. 479) 6. Provide 6. If the client is ill, psychological ascertain the support/motivation motivation for . returning to an optimal level of wellness. (Medical-Surgical Nursing, 7th ed. by Black, Joyce M. and Jane Hokanson Hawks; p. 75) 7. Encourage 7. To promote mobilization of the circulation and left upper prevent excessive extremity. Assist tissue pressure. with ROM (Fundamentals of exercises. Nursing 7th ed. by Kozier, Barbara, p. 535) 8. Encourage adequate periods 8. To prevent fatigue. (Nurse’s Pocket

APPROPRIATENESS: Were the interventions suitable to client’s situation? __yes __no why? Were the setting and time table interventions realistic to client’s situation? __yes __no why? ACCEPTABILITY: Were the interventions accepted by the patient (without any signs of rejection from the patient and family members)? __yes __no why? ADEQUACY: Was the number of interventions sufficient to meet the desired goal and objectives? __yes __no why?

of rest and sleep, including uninterrupted periods of sufficient duration, meeting comfort needs, limiting/ avoiding use of caffeine/ alcohol and medications affecting REM sleep. Encourage quiet, restful atmosphere.

Guide, 9th ed. by Doenges, Marilynn, et.al., p. 369)

9. Discuss with 9. Promotes early relatives the detection of importance of developing early detection and complications. reporting of (Fundamentals of changes in Nursing 7th ed. by condition or any Kozier, Barbara, p. unusual physical 536) discomforts/ changes. 10. Teach the client and significant others about the nonpharmacologic ways to lessen pain. 10. It may be possible to teach clients a combination of these techniques to maximize their opportunities for self-control over

manifestations of pain. (MedicalSurgical Nursing, 7th ed. by Black, Joyce M. and Jane Hokanson Hawks; p. 476) 11. Notify physician if regimen is inadequate. 11. To meet pain control goal. (Nurse’s Pocket Guide, 9th ed. by Doenges, Marilynn, et.al., p. 368)

COLLABORATIVE: COLLABORATIVE: 1. Necessary for 1. Administer treatment of the medications underlying cause. (particularly (Nurse’s Pocket analgesics) as Guide, 9th ed. by prescribed. Doenges, Marilynn, et.al., p. 542) To maintain acceptable level of pain. (Nurse’s Pocket Guide, 9th ed. by Doenges, Marilynn, et.al., p. 368) 2. To determine changes indicative

2. Assist with laboratory/diagnos tic studies as indicated. (e.g., Chest Ultrasound).

of healing/ infection/ complications. To identify causative/precipitating factors. (Nurse’s Pocket Guide, 9th ed. by Doenges, Marilynn, et.al., p. 70)

XI. NURSING CARE PLANS

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