Nursing Diagnosis / Scientific Explanation
Problems in Nursing Objectives
Collaboration
Acute pain related In performing
to cholecystectomy, surgical
cholecystectomy incision is done.
surgery evidenced First, tissue damage
by patient releases chemical
verbalizing pain mediators, such as
6/10, stabbing pain prostaglandins, bradykinin,
on his abdominal serotonin, substance P, and
sites with no histamine. These
radiation, and substances then activate
provoked by nociceptors, resulting in
movement. transduction, or the
generation of an action
potential (an electrical
impulse). In the second
process -transmission- the
action potential moves from
the site of injury along
afferent nerve fibers
nociceptors at the spinal
cord. Release of substance
Expected Outcomes/ Nursing Interventions Rationale of the Evaluation
Interventions
By the end of my Assessment: Patient reported his
shift, the patient will 1-Assess vital signs 1-Rise of BP, HR, and pain has decreased
be able to: (BP, HR, RR, Temp). temperature may to minimal level
indicate acute pain. which the outcome
1-report increased has completely met.
comfort and 2-Assess for 2-Changes can
describe satisfactory peripheral pulses and indicate ineffective 1-Vitale sign- stable.
pain control at a capillary refill. ventilation or
level less than 3 on respiratory distress or 2-Pulses were
a scale pain of 1 to circulatory disturbance presented on his
10. in extremities. upper/lower
extremities.
2-show improved 3-Assess pain 3-To improve pain
wellbeing such as characteristics of management 3-The patient felt no
baseline levels for PQRSTU. strategies. stabbing/tangling
vital signs (BP, HR, pain.
and RR) and 4-Assess for burning, 4-Effects and results
peripheral pulse. numbness and from hip replacement 4-The patient
tangling in surgical to spinal nerve root verbalized more
3-Notify the health sites. irritation. comfort after
care provider of pain administration of
P and other
neurotransmitters carry the
action potential across the
cleft to the dorsal horn of the
spinal cord, from where it
ascends the spinothalamic
tract to the thalamus and the
midbrain. Finally, from the
thalamus, fibers send the
nociceptive message to the
somatosensory cortex,
parietal lobe, frontal lobe,
and the limbic system,
where the third nociceptive
process -perception- occurs.
before the pain 5-Assess for 5-Indication for medications for pain
becomes ability/inability of complications of relief.
unbearable. movement in bed. immobility.
5-The patient was
6-Monitor and record 6-May indicate for able to sleep and
neurological signs abnormality or spinal relax after the
every 4 hours. infection. medications.
Interventions
7-Administer 7-To reduce pain. 6-The patient
Paracetamol for pain reduced his stress by
relief as ordered. integrating with his
wife and staff
8-Provide rest period 8-Fatigue may result nurse/student nurse.
to promote relief, in exaggerated pain.
sleep and relaxation.

9-Use non- 9-To reduce the stress

pharmacological and tension which
techniques decreases the pain
(relaxation exercise according to gate
and listening to control therapy.
music…).

10- Provide non- 10-To provide comfort.

pharmacological
 intervention such as
touch and frequent
changing of position.
Teaching:
11-Educate the 11-To improve the
patient relaxation patient’s coping to
technique and stress induced by pain
reduction of stressors which decreases the
and factors. pain as addition
stressors can intensify
pain.
12-Educate family 12-According to the
members to initiate gate control theory,
frequent visits to the identified cognitive
patient and behavioral
encourage the approaches to pain
patient to do management. A
something they like distraction and social
for example music. support help relieve
pain.

Updated by V.G Fall 2017 Page 16