NURSING CARE PLAN

Assessment Subjective: Masakit ang banding gitna ng likod ko as verbalized by the patient. -Aching -Onset is indefinite -Localized in the middle area of the back -Pain goes away for up to 30 minutes at times but recurs again -Pain scale of 6/10, when not moved -With pulsation

Diagnosis Chronic pain related to thoracic compression as manifested by facial grimace and guarding behavior

Inference Precipitating factors: -Obesity -Work: (junkerheavy lifter) and Predisposing factors: -T8 spinal abscess -Kyphosis T9 spinal compression Alteration of peripheral nervous system impulses (T8T9) Nociception Transmission

Planning Short term:

Intervention Independent:

Rationale

Evaluation Short term: After an hour of nursing interventions, the patient was able to verbalize that pain is relieved/ controlled as evidenced by pain scale of 3/10 or lower Long term: After 3days of nursing interventions, the patient was able to verbalize nonpharmacologic methods that provide relief and follow prescribed pharmacological regimen

After an hour of nursing -Assess for pain interventions, the tolerance patient will be able to verbalize that pain is relieved/ controlled as evidenced by pain scale of 3/10 or lower -Note cultural Long term: and developmental After 3days of influences nursing affecting pain interventions, the patient will be able to verbalize non-Provide comfort pharmacologic measures, quiet methods that environment, provide relief and calm and follow activities prescribed

-To help determine possibility of underlying condition or organ dysfunction requiring treatment -Verbal or behavioral cues may have no direct relationship to the degree of pain perceived -To promote nonpharmacological pain management

-Pain worsens when repositioning (9/10) Objectives: -Body temperature of 36.8C rose to 37.3C in 4 hours -Facial grimace noted -Observed evidence of pain during repositioning -restlessness -sleep disturbance -Spinal cord (T8) abscess -T9 compression

and pharmacological interpretation of regimen pain signal to the brain Localized midposterior pain Guarding behavior; restlessness; irritability The gate control theory of pain is the idea that physical pain is not a direct result of activation of pain receptor neurons, but rather its perception is modulated by interaction between different neurons.

-Note when pain occurs -Investigate report of pain, noting characteristics, location, intensity (0-10 scale) -Provide firm mattress and small pillows

-To medicate prophylactically, as appropriate -Helpful in determining pain management needs and effectiveness of the program -Soft or sagging mattresses and large pillows inhibit the proper body alignment -In acute phase, total bed rest maybe necessary to limit pain

-Suggest patient to assume position of proper comfort while in bed. Promote bed rest as indicated -Encourage frequent changes of position -Encourage use of stress

-Prevent general fatigue and joint stiffness -Promotes relaxation,

via CT Scan -Guarding behavior

management techniques

provides sense of control and may enhance coping activities -Increasing/ decreasing dosage, stepped program helps in self-management of pain

-Evaluate/ document patients response to analgesia, and assist in transitioning/ altering drug regimen, based on individual needs Dependent: -Administer/ monitor medication such as analgesics/, as indicated, to maximum dosage, as needed -Administer antibiotic as prescribed

-To maintain acceptable level of pain. Notify the physician if regimen is inadequate to meet pain control goal -To prevent further infection

Collaborative: -Coordinate with medical technologists, radiation technologists, nuclear medicine department -Coordinate with dietician, nutritionist -Coordinate with charitable institution and HMO -Coordinate with spiritual counselor Source: Gate Control Theory of Pain. (n.d.). Science Daily. Retrieved September 30, 2011, from www.sciencedaily.com/articles/g/gate_control_theory_of_pain.htm Doenges, M.E. et.al (2006). Nurses Pocket Guide: Diagnoses, Prioritized Interventions, and Rationale. ed. 10. 392-396 -For further diagnostic or laboratory evaluation

-To promote wellness -To provide financial support

-To support patient and family spiritually