ACUTE PAIN

Nursing Diagnosis: Acute pain related to progressive bone destruction and microcellular
damage secondary to Pott’s Disease as evidenced a pain scale of 7/10, grimacing face,
narrowed focus and with a verbalization of “nagsakit tuy likod ko”.

Nursing Inference: Pott’s disease is the hematogenous spread of M. tuberculosis into the
dense vasculature of cancellous bone of the vertebral bodies. Further, it would spread from
two adjacent vertebrae into the adjoining intervertebral disc space, this would cause break
down and death of disk tissue by caseation leading to progressive bone destruction. As bone
destruction progresses, this leads to spinal cord narrowing and compression. Thus, acute
pain.

Nursing Goals: After 1 hour to 2 hours of rendering nursing interventions, the patient will
report pain is relieved with a pain scale of 2-3/10, absence of grimacing face and narrowed
focus with a verbalization of “Hindi na gaanong masakit ang likod ko” and the patient will be
able to follow prescribed pharmacological and non-pharmacological regimen.

Intervention Rationale
Investigate report of pain, noting To determine pain management needs and
characteristics, location, intensity (0-10 effectiveness of the program.
scale).
Administered non-steroidal anti- These drugs control mild to moderate pain
inflammatory drugs as prescribed. and inflammation by inhibition of
prostaglandin synthesis 
Administer antibiotic as prescribed. To prevent further infection.
Provide firm mattress and small pillows. Soft or sagging mattress and large pillows
inhibits the proper body alignment.
Suggest patient assume position of proper In acute phase, total bed rest may be
comfort while in bed or chair. Promote bed necessary to limit pain.
rest as indicated.
Encourage frequent changes of position. Prevents general fatigue and joint stiffness.
Apply warm or moist compress on the Heat promotes muscle relaxation and
affected area several times a day. mobility, decreases pain and relieves
morning stiffness.
Provide gentle massage. Promotes relaxation and reduces muscle
tension.
Encourage patient use of relaxation To promote non-pharmacological pain
techniques such as breathing exercise, management.
adequate rest, sleep and use of stress
management techniques.
Encourage diversional activities To distract attention and reduce tension.

Evaluation: After 1 hour of rendering nursing interventions, the patient was able to report
pain is relieved with a pain scale of 2/10, absence of grimacing face and narrowed focus with
a verbalization of “Hindi na gaanong masakit ang likod ko” and the patient was able to follow
prescribed pharmacological and non-pharmacological regimen.