A.

Assessment

The main complaint: pain when swallowing Subjective

data:

-          Can not sleep because the mouth feels dry and hot and painful when swallowing

-          Complained of nausea, no appetite, felt like vomiting, and stomach felt tight

Objective data:

-          The patient looks tired, the oral mucosa is dry, the skin tug is moderate, looks painful
when swallowing

-          The throat looks reddish

-          BW before sickness 70 kg, currently 60 kg

-          Hb 11 gr / dl

-          Albumin 3.5 mg / 100 ml

B. Diagnose

Acute pain bd biological injury agents w / changes in appetite, reports of painful behavior /
activity changes in

Defenision

unpleasant sensory and emotional experiences arising from actual or potential tissue damage or
described in terms of such damage (International Association for the Study of Pain) , a sudden or
slow onset of mild to severe intensity with a predictable or predictable ending lasting less than 3
months.
 C. Intervention 

NOC NIC

·         pain control Pain management: acute

·         pain level
After taking action for 24 hours,
acute pain was resolved with the
following criteria:
-          can recognize when pain
occurs
-          can use pain precautions
-          can do pain reduction
without analgesics
-          be able to recognize what
the pain symptom is associated
with
-          reported pain (increased to
3)
-          facial pain expression
(upgraded to 3)
-          unable to rest (upgraded to
3)
-          loss of appetite (increased to
3)
-          nausea (upgraded to 4)
-          food intolerance (increased
to 3)
   
-          Perform a thorough pain assessment
-          ask the patient about the level of pain that remains
comfortable and functions that attempt to keep the pain at a
level lower than the pain indicated
-          make sure that the patient is receiving appropriate
analgesic treatment before pain becomes severe
Relaxation therapy
-          provide a detailed description of the relaxation
intervention chosen
-          get behaviors that indicate relaxation
-          ask the client to relax
-          demonstrate and practice relaxation techniques to
clients
-          use relaxation as an adjunct strategy with
appropriate use of pain medications or other therapies

D. Implementation

Management: Acute

-          Perform a thorough pain assessment

-          Ask the patient about the level of pain that remains comfortable and functions that attempt
to keep the pain at a lower level than indicated pain

-          Ensure that the patient receives appropriate analgesic treatment before pain becomes
severe
 

Relaxation Therapy

-          Provide a detailed description of the relaxation intervention chosen

-          Get behaviors that indicate relaxation

-          Ask clients to relax

-          Demonstrate and practice relaxation techniques to clients.

Use relaxation as an adjunct strategy with appropriate use of pain medications or other therapies

E. Evaluation nursing

S:

-          The patient complains of pain when swallowing

O:

-          The patient appears weak

-          The patient appears to be in pain when swallowing

-          The throat looks reddish

A:

Acute pain is partially resolved

P:

Advanced Intervention:

-          Pain Management: Acute

Relaxation Therapy