NCP# 1

ASSESSMEN NURSING NURSING NURSING RATIONALE

T DIAGNOSI GOAL INTERVENTION
S
SUBJECTIVE Chronic After 8 hours INDEPENDENT INDEPENDENT
CUES: pain r/t of nurse- 1. Investigate reports 1. Self-report should be
as verbalized inflammatio patient of pain, noting the primary source of
by the patient. n and interaction, the location and pain assessment in
increased patient will be intensity using a 0 to determining pain
disease able to: 10 (or similar) scale. management needs
OBJECTIVE activity, Note precipitating and effectiveness of
CUES: tissue a. factors and program.
- Facial damage, nonverbal pain
grimacing and fatigue. cues.
- Pain scale: 2. Suggest patient 2. In severe disease or
9/10 assume a position acute exacerbation,
- V/S taken as of comfort while in total bedrest may be
follows: bed or sitting in a necessary until
T: °C chair. Promote bed objective and
PR: bpm rest as indicated. subjective
RR: cpm improvements are
BP: mmHg noted to limit pain and
injury to joint.
3. Encourage frequent 3. Prevents general
LAB changes of position. fatigue and joint
RESULTS: Assist the patient to stiffness. Stabilizes
move in bed, joint, decreasing joint
CBC: supporting affected movement and
WBC - 14.5 joints above and associated pain.
10˄9/L below, avoiding
RBC - 3.5 jerky movements.
10˄12/L 4. Recommend that 4. Heat promotes
Platelet - 460 patient take a warm muscle relaxation and
10˄9/L bath or shower upon mobility, decreases
arising or at pain and relieves
Erythrocyte bedtime. Apply morning stiffness.
Sedimentation warm, moist Sensitivity to heat
Rate (ESR): 60 compresses to may be diminished
mm/hr affected joints and dermal injury
several times a day. may occur.
Monitor water
temperature of
compress, baths
and so on.
5. Encourage the use 5. Promotes relaxation,
of stress provides a sense of
management control and may
techniques such as enhance coping
progressive abilities.
relaxations, guided
imagery, self-
hypnosis and
controlled breathing.
Provide therapeutic
touch.
6. Involve client in 6. Refocuses attention,
diversional activities provides stimulation,
appropriate for and enhances self-
individual situation. esteem and feelings
of general well-being.

DEPENDENT DEPENDENT
1. Medicate before 1. Promotes relaxation,
planned activities reduces muscle
and exercises, as tension and spasms,
indicated. facilitating
participation in
therapy.
2. Administer 2. Because irreversible
medications, as joint damage occurs
indicated, for within the first 2
example: years, early diagnosis
Analgesics, and intervention are
DMARDS, necessary.
Corticosteroids, etc. Medications are the
mainstay of treatment
with a goal of
managing pain,
slowing joint
destruction, and
preserving joint
function.
3. Apply ice or cold 3. Cold may relieve pain
packs when and swelling during
indicated. acute episodes.

COLLABORATIVE COLLABORATIVE
1. Assist with physical 1. Provides sustained
therapies, such as heat to reduce pain
paraffin gloves or and improve ROM of
whirl pool baths. affected joints.
2. Prepare for surgical 2. Corrective surgical
interventions, such procedures may be
as synovectomy, indicated to reduce
total joint pain and/or improve
replacement, joint joint function and
fusion; tunnel mobility.
release procedures;
and tendon repair.