Medical Diagnosis: Chronic Renal Failure Problem: Acute Pain Assessment Subjective: (none) Objective: Facial Grimaces Guarding

ng behaviors Costovertebral pain/ Flank pain Limited ROM Body weakness Facial Mask Narrowed Focus Sleep Disturbance Diaphoresis RR & BP changes (Dont forget which of the following signs and symptoms above that the patient manifested and may manifest) Nursing Diagnosis Acute Pain Scientific Explanation Pain is a discomfort that is caused by the stimulation of the nerve endings. Any trauma that the kidney experience (by any caused or factors) perceive by the body as a threat, the body releases cytokine and prostaglandin causing pain which is felt by the patient at his/her costovertebral area/flank. Planning Short Term: After 6-8 hours of nursing interventions, the patient will demonstrate use of relaxation skills to relieve pain. Interventions 1. Establish rapport. Rationale 1. To get the cooperation of the patient and SO. Evaluation Short Term: The patient shall have demonstrated use of relaxation skills to relieve pain. (Use pain scale here)

2. Monitor and record vital signs. 3. Assess pts general condition

2. To obtain baseline data. Long Term: The patient shall have reported pain relief or control.

Long Term: After 2-3 days of nursing interventions, the patient will report relief/control of pain.

4. Accept patients description of pain.

3. To obtain baseline data

4. Pain is a subjective experience and cannot be felt by other. 5. Perform a comprehensive assessment of pain ( location , onset, characteristics, frequency) 5. To be able to compare changes from previous reports to rule out worsening of underlying condition/develo ping complications

6. Determine

6. To know

possible pathophysiology and causes of pain

underlying condition that leads to pain and possible management that would not further aggravate pain.

7. Assess patients perception along with behavioral and physiological responses.

7. To know clients attitude towards pain and use of specific pain and medication.

8. Perform pain assessment each time pan occurs, note and investigate changes from previous report. 9. Assess patients description of pain.

8. To rule out worsening of underlying condition / development of complication.

9. To acknowledge the pain experience convey acceptance of clients response to pain.

10. Observe nonverbal cues including how client walks, holds

10. Observation may/ may not be congruent with

body, sits, facial expressions, cool fingertips/ toes, which can mean constricted vessels

verbal reports indicating need for further evaluation.

11. Assess for referral pain as appropriate

11. To help determine possibility of underlying condition or organ dysfunction requiring treatment. 12. To rule out worsening of pain due to methods used.

12. Review patients previous experiences with pain and methods found either helpful or unhelpful for pain control in the past.

13. Explore method for alleviation/ control of pain.

14. Encourage verbalization of feelings about the pain.

13. Timely intervention is more likely to be successful in alleviating pain. 14. To allow out let for emotions and enhance coping mechanism.

15. Provide quite environment, calm activities and adequate rest reinforce 16. Provide comfort measures such as back rub, change position, use of heat/ cold. 17. Instruct/encourage use of relaxation exercise such as focused breathing. 18. Encourage diversional activities such as TV and socialization with others.

15. To prevent fatigue and lessen stimuli.

16. To provide nonpharmacologic pain management.

17. This is a form of relaxation technique that helps decrease level of pain.

19. Assist with selfcare activities.

18. Provides divertionary activities that help block the perception of pain by the brain.

20. Assist in treatment of underlying disease process causing pain. 21. Provide for individualized

19. To able to perform ADLs and maintain good hygiene.

physical therapy/ exercise program that can be continued by the client discharge refer to physical therapist.

22. Administer analgesics as ordered.

20. Evaluate effectiveness of therapies. 21. To continue therapeutic effect and wellness for the patient 22. Pharmacologic mgmt for pain