ASSESSMENT

EXPLANATION OF THE PROBLEM Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months Pain is a highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors may be experienced by the sufferer. Pain may be a symptom of injury or illness. Pain may also arise from emotional, psychological, cultural, or spiritual distress. Pain can be very difficult to explain, because it is

OBJECTIVES Dx.

INTERVENTIONS

RATIONALE

EVALUATION

S: O: grimaces noted weak in appearance restlessness V/S as follows: BP: RR: PR: TEMP:

Short term objectives: After 30 minutes of effective nursing interventions, the patient will be able to:

Monitored vital signs and recorded.

Serves as baseline data and usually altered when in pain. Pain is a subjective experience and must be described by the client in order to plan an effective treatment. Some patients may verbally deny pain when it is still present. Restlessness , inability to focus, frowning, grimacing and guarding of the area may be nonverbal signs of acute pain.

Short term objectives: After 3o minutes of effective nursing interventions the patient is able to demonstrate proper pain management such as deep breathing exercises and able to verbalize methods that provide pain relief therefore the goal is met. Long term objectives: After 24 hours of nursing interventions the patient is already in relax posture, facial expression and able to rest and sleep though verbalize to have a temporary relief of pain therefore the goal was partially met.

a. Demonstrate use of non-pharmacological pain management such as deep breathing exercises. b. Verbalized methods that provide pain relief.

Assess location, characteristics, onset, duration, frequency, quality, intensity and severity of pain. Assessed nonverbal cues of pain.

Long term Objectives: After 24 hours of effective nursing interventions, the patient will: a. Demonstrate relax posture, facial expressions and ability to rest and sleep. b. Verbalize sufficient relief of pain or ability to cope with incompletely relieved pain Established rapport. Provided rest periods, sleep and relaxation.

Tx.

unique to the individual; pain should be accepted as described by the sufferer.

Gain trust and cooperation. Outside sources of stress, anxiety and lack of sleep all may exaggerate the patients perception of pain. Provide client comfort and needs. This may help decreased pain perception.

Rendered bedside care.

Promoted divertional activities.

Raised bed side rails.

EDx.

Encouraged deep breathing exercises. Emphasized importance of proper hand washing and personal hygiene. Encouraged verbalizations of feelings and discomfort.

Ensure safety and security.

For relaxation

Encouraged adequate rest

Decreases the risk of contamination and infection.

periods. Offering self makes nurse readily anticipates and attend clients needs. Reduces or prevent fatigue.