This action might not be possible to undo. Are you sure you want to continue?
Name of Patient: Montalban Rizal Age: 45 years old Diagnosis: Acute Pyelonephritis CUES INTERACTION “Masakit ung dito (pertaining to the lower abdomen), tapos pag gumagalaw ako masakit din. Minsan sa likod, tapos dito sa baba ng dibdib.” - When asked to describe the intensity of pain on a scale of 1-10, the patient said its 6 OBSERVATIONS patient’s facial expressions show signs of pain - guarding behavior on the lower abdomen - patient looks restless and weak NURSING DIAGNOSIS Acute pain related to acute inflammation of renal tissues as manifested by patient’s verbalization, behavior, and changes in vital signs ANALYSIS/HEALTH IMPLICATION IMMEDIATE CAUSE Acute inflammation of renal tissues INTERMEDIATE CAUSE Acute pyelonephritis ROOT CAUSE Stone formation HEALTH IMPLICATION Genitourinary pain is usually caused by distension of some portion of the urinary tract because of obstructed urine flow or inflammation and swelling of tissues. Severity of pain of pain is related to the sudden onset rather than the extent of distension. Unrelived acute pain can affect the pulmonary, cardiovascular, gastrointestinal, endocrine, and immune systems. The GOAL AND OBJECTIVES GOAL After 8 hours of nursing intervention, the client will be able to report relief/control of pain. OBJECTIVES 1) After 15-20 minutes of physical assessment, the client will be assessed for precipitating/ contributing factors of his pain. 1) Perform physical assessment which includes location and characteristics of pain Pain is a subjective experience and must be described by the client in order to plan effective treatment. Kozier, Fundamentals of Nursing, 7th ed., p.1164 Provides baseline for assessing changes in pain level and evaluating interventions. Smeltzer & Bare, Medical Surgical 1) Was the client able to be assessed for precipitating/ contributing factors of his pain after 1520 minutes of physical assessment? Yes __ No __ If No, Why? NURSING INTERVENTIONS RATIONALE EVALUATION
a. Use pain assessment scale to identify intensity of pain.
CUES MEASUREMENT Blood Pressure: 150/90 up to 160/90 mmHg Respiratory rate: 25 up to 28 breaths per min
ANALYSIS/HEALTH IMPLICATION stress response (“neuroendocrine response to stress”) that occurs with trauma also occurs with other causes of severe pain. The widespread endocrine, immunologic, and inflammatory changes that occur with stress can have significant negative effects. This is particularly harmful in patients compromised by age, illness, or injury. Smeltzer & Bare, Medical Surgical Nursing, 10th ed., pp.218,1259
GOAL AND OBJECTIVES
RATIONALE Nursing, 10th ed., pp.245
b. Assess and record pain and its characteristics: location, quality, frequency and duration.
Data assist in evaluating pain and pain relief and identifying multiple sources and types of pain. Smeltzer & Bare, Medical Surgical Nursing, 10th ed., pp.245 Each person experiences and expresses pain in an individual manner using a variety of social adaptation techniques. Kozier, Fundamentals of Nursing, 7th ed., p.1164 Usually altered in acute pain. Doenges, Moorhouse, Geissler-Murr, Nurse’s Pocket Guide, 9th ed., p.367 Personal factors can influence pain and pain tolerance. Those 2) Was the client able to verbalize reduction of precipitating
c. Note cultural and developmental influences affecting pain response.
d. Monitor vital signs.
2) After 10-15 minutes of interaction, the client will be able
Discuss with the client the importance of eliminating precipitating factors
GOAL AND OBJECTIVES to verbalize reduction of precipitating factors of pain.
NURSING INTERVENTIONS such as fear, fatigue, anxiety, and stress.
RATIONALE factors that may be precipitating or augmenting pain should be reduced or eliminated to enhance the overall pain management program. Fundamentals of Nursing, 7th ed., p.1164 The use of noninvasive pain relief measures can increase the release of endorphins and enhance the therapeutic effects of pain relief medications. Fundamentals of Nursing, 7th ed., p.1164 To prevent fatigue. Doenges, Moorhouse, Geissler-Murr, Nurse’s Pocket Guide, 9th ed., p.367 Analgesics are more effective if
EVALUATION factors of pain after 10-15 minutes of interaction? Yes __ No __ If No, Why?
3) After 20-30 minutes of intervention, the client will be provided with nonpharmacologic measures to reduce pain.
a. Teach patient the use of nonpharmacologic techniques such as relaxation, music therapy or distraction.
3) Was the client able to be provided with nonpharmacologic measures to reduce pain after 20-30 minutes of intervention? Yes __ No __ If No, Why?
b. Encourage adequate rest periods.
4) After 5 minutes of drug
4) Was the client
GOAL AND OBJECTIVES administration, the client will be given analgesics as prescribed by the physician.
NURSING INTERVENTIONS (Voltaren) 50mg 1 tab PRN for pain as prescribed by the physician.
RATIONALE administered early in pain cycle. Simultaneous use of analgesics that work on different portions of the nociceptive system will provide greater pain relief with fewer side effects. Smeltzer & Bare, Medical Surgical Nursing, 10th ed., pp.245 The analgesic dose may not be adequate to raise the client’s pain threshold or may be causing intolerable or dangerous side effects or both. Fundamentals of Nursing, 7th ed., p.1164
EVALUATION able to be given analgesics as prescribed by the physician after 5 minutes of drug administration? Yes __ No __ If No, Why?
a. Evaluate the effectiveness of analgesic at regular frequent intervals after each administration. b. Instruct patient and family about potential side effects of analgesics and their prevention and management.