Patient Initials: GA Date of Care: 11/17/2010
ASSESSMENT SUPPORTIVE DATA S. Patient reports of continued “burning” epigastric pain O. - Grimacing on face when changing positions (Pain is a subjective response. Sometimes there are outside signs someone is pain but since I have not cared for this patient yet and there isn’t any objective data for me to notate other than that which is in the patient’s file) ANALYSIS NURSING DIAGNOSIS Acute Pain R/T Inflammation of the gastric mucosa ST: Patient will verbalize a reduction in pain by end of shift today LT: Patient will have resolution to gastritis Patient will have no epigastric pain at discharge Outcomes - Patient will express a feeling of comfort and relief from pain - Increased appetite and gain of at least 5 lbs -Decreased anxiety related to health - Assess for signs/symptoms of pain. -Assess clients pain perception utilizing a rating scale of 1-10 -Position for comfort and provide additional comfort measures as needed -Teach Patient the use of and assist patient with non pharmacological approaches to pain management such as heat/cold application, distraction techniques, relaxation breathing, visualization, and/or listening to music. - Teach patient to avoid spicy foods and to implement a diet low in fat Dependent -Administer analgesic pain medication per physician orders. Aspirin 81 mg PO; Ultram 50 mg. PO PLANNING CLIENT GOALS OUTCOME CRITERIA Goal IMPLEMENTATION NURSING ACTIONS Independent - Early recognition of signs and symptoms of pain allows for prompt intervention and improved pain control - An awareness in the severity of pain being experienced by the patient helps determine the most appropriate pain interventions. The use of a pain scale promotes a more consistent communication between care givers when discussing the patients pain experience - When patients are comfortable their pain may be diminished -Nonpharmalogical pain management can help decrease pain by promoting relaxation. It is believed that most of these interventions are effective because they stimulate the closure of the gating mechanism in the spinal cord and can thus block the transmission of pain. - Avoiding a diet with excess fat will help the gastric mucosa heal and help with inflammation -Administering analgesics helps control a patients pain by blocking the pain receptors SCIENTIFIC PRINCIPLES/ RATIONALE

Student Name: KB

Partially met?

Not met?

Definition of Nursing Diagnosis: Acute Pain- Unpleasant sensory & emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden slow onset of any intensity from mild to severe with an anticipated or predictable end or duration of less than 6 months.

References: Sparks, S., & Taylor, C. (2010). Nursing diagnosis: Pocket Guide, pp. 248-249) Lewis, Sharon; Heitkemper, Margaret; Dirksen, Shannon; O’Brien, Patricia; Bucher, Linda. 2007. Medical Surgical Nursing: Assessment and management of clinical problems Mosby Elsevier, St. Louis, MO. Pgs.1043-1046.

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