NURSING CARE PLAN NURSING DIAGNOSIS Acute pain related to inflammation of the liver secondary to upper GI bleeding and

esophageal varices as evidenced by pallor, guarded behavior, restlessness, selffocusing, facial grimace, limited ROM, BP= 140/80 mmHg, PR= 80 beats/min, RR= 24 breaths/min with a pain scale of 7/10 and as verbalized by client, kasakit gid sang akon tiyan. GOAL Within 1 hour of nursing interventions, client will report that pain is relieved or controlled. NURSING INTERVENTIONS Independent: Monitor vital signs. Perform a comprehensive assessment of pain including location, characteristics, onset/duration, frequency, quality, severity, & precipitating/aggravating factors. Observe or monitor signs and symptoms associated with pain such as blood pressure, heart rate, temperature, color and moisture of skin, restlessness, and ability to focus. Assess for probable cause of pain. To obtain baseline data. Pain is a subjective experience and must be described by the client in order to plan effective treatment. RATIONALE EVALUATION After 1 hour of nursing interventions, goal met. Client reported that pain is controlled with a pain scale of 4/10. He seldom exhibits guarding behavior and facial grimace. Vital signs are within normal range with BP= 120/70 mmHg, RR= 20 breaths/min, PR= 71 beats/min, T=37.1oC.

Some people deny the experience of pain when it is present. Attention to associated signs may help the nurse in evaluating pain.

Different etiological factors respond better to different therapies. Prompt responses to complaints may result in decreased anxiety. Demonstrated concern for the patients welfare & comfort fosters the development of a trusting relationship. The use of noninvasive pain relief measures can increase the re- lease of endorphins and enhance the therapeutic effects of pain relief medications.

Respond immediately to complaints of pain.

Teach the use of nonpharmacologic techniques (e.g., relaxation,guided imagery, music therapy, distraction, and massage) before,after, and if possible during painful activities; before pain occurs orincreases; and along with other pain relief measures. Evaluate patients response to pain and medications or therapeutics aimed at abolishing or relieving pain.

It is important to help patients express as factually as possible (i.e., without the effect of mood, emotion, or anxiety) the effect of pain

relief measures. Discrepancies between behavior or appearance and what patient says about pain relief (or lack of it) may be more a reflection of other methods patient is using to cope with than pain relief itself. Elicit behaviors that are conditioned to produce relaxation, such as deep breathing, yawning, abdominal breathing, or peaceful imaging Eliminate additional stressors or sources of discomfort whenever possible. Create a quiet, nondisruptive environment with a comfortable temperature when possible. Relaxation techniques help reduce skeletal muscle tension, which will reduce the intensity of the pain

Patients may experience an exaggeration in pain or a decreased ability to tolerate painful stimuli if environmental, intrapersonal, or intrapsychic factors are further stressing them. Comfort and a quiet atmosphere promote a relaxed feeling and permit the client to focus on the relaxation technique rather than external distraction. The patients experiences of pain may become exaggerated as the result of fatigue. In a cyclic fashion, pain may result in fatigue, which may result in exaggerated pain and exhaustion. A quiet environment, a darkened room, and a disconnected phone are all measures geared toward facilitating rest.

Provide rest periods to facilitate comfort, sleep, and relaxation.

Dependent: Administer prescribed medications as ordered by the physician: - Mefenamic acid PRN for pain

Thought to inhibit prostaglandin synthesis to produce anti-inflammatory analgesic & antipyretic effects. It is thought to bind to opioid receptors & inhibit reuptake or norepinephrine and serotonin.

Interdependent: Notify the physician if interventions are unsuccessful or if current complaint is a

Patients who request pain medications at more frequent intervals that prescribed may actually

significant change from the patients past experience of pain. Collaborate with the health care providers for patients optimal pain management if measures done to him is not effective.

require higher doses or more potent analgesics.

Individualizing the pain relieving regimen recognizes the individual differences in pain perception & provides for more effective control. NSAIDS are used alone for mild pain & in combination with opioids for moderate or severe pain.