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NCP

Nursing Nursing Analysis Goal and Interventions Rationale Evaluation


Problem Cues Diagnosis Objectives
Subjective: Acute Pain Arthritis is a GOAL After the 8 hour
 The related to general term After the 8 hour shift, the client will
patient accumulation that means shift, the client will was able to
verbalized of inflammation in a be able to verbalize decreased
that she is fluid/inflamma joint. Joint verbalize pain as evidenced
experienci tory process, inflammation is decreased pain as by a pain scale of
ng pain at degeneration characterized by evidenced by a 3/10
her right of joint, and redness, warmth, pain scale of 3/10.
knee and deformity, swelling, and INDEPENDENT
there is possibly pain within the OBJECTIVE: 1.1 Establish a  A Trusting
limited evidenced by joint. trusting relationship EFFECTIVENESS:
movemen verbal reports The autoimmune 1.After 10 minutes relationship with promotes 1. After 10 minutes
t due to and physical reaction of nursing the client expression of of nursing
pain, but immobility. primarilu occurs interventions, the the client’s interventions, the
she in the snovial client will be able thoughts and client was able to
explained tissue. to express fully her feelings and express fully her
that this Phagocytosis perception of pain enhances perception of pain.
happens produces effectiveness of
irregularly enzymes within planned pain
and when the joint. The therapies.
it attacks enzymes break (Fundamentals
she can’t down collagen, of Nursing by
even causing edema, Kozier, Erb,
sleep due proliferation of 1.2 Convey your Berman,
to too the synovial concerns and Snyder, p.
much membrane, and encourage client to 1149)
pain. ultimately verbalize feelings
 She pannus about pain.  Clients who
doesn’t formation. are able to
take any Pannus destroys express pain to
medicatio cartilage and an attentive
n for the erodes the bone. listener and
pain she There is loss of participate in
stated articular pain
“pinapalig surfaces and management
o ko lang joint motion. decisions can
pag Tendon and increase a
sumasakit ligament a. Use pain sense of control
tapos pag elasticity and assessment and decrease in
gisig ko contractile power scale to pain perception.
kinabukas are lost. identify (Fundamentals
an intensity of of Nursing by
nawawala Textbook of pain. Kozier, Erb,
din Medical-Surgical Berman,
namaneh. Nursing by Snyder, p.
” Smeltzer and 1140)
Hinkle, p1906  Provides
Objective: baseline for
 She assessing
rated the b. Assess and changes in pain
pain as record pain level and
7/10. and its evaluating
characteristi interventions.
cs: location, (Medical
quality, Surgical
frequency, Nursing by
and duration Smeltzer, Bare,
Hinkle,
Cheever, p.
294)

c. Assess  Data assist


patient’s in evaluating
past coping pain and pain
mechanisms. relief in
2. After 4 hours of identifying
nursing multiple 2. After 4 hours of
interventions the sources and nursing
client will be able types of pain. interventions the
to report (Medical client was able to
diminished pain 2.1 Provide Surgical report diminished
through non- client physical Nursing by pain through non-
pharmacologic care and comfort Smeltzer, Bare, pharmacologic
methods. by placing client Hinkle, methods.
in a comfortable Cheever, p.
position, offering 294)
a fresh gown,
changing bed  To
linens along with determine
efforts to make measures that
the person feel worked best in
refreshed the past .
(brushing teeth, (Nursing Care
combing hair). Plans by
Gulanick, Klopp,
2.2 Teach client Galanis,
how to perform Gradishar,
different pain Puzeas, p. 50)
relief measures
(non-  Increases
pharmacologic) the level of
Inform patient comfort and
that these improve the
methods are done effectiveness of
before pain occurs pain relief
or increases, and measures. .
along with other (Medical
pain relief Surgical
measures. Nursing by
Smeltzer, Bare,
Hinkle,
Cheever, p.
276)

a. Cutaneous
stimulation
(Massage)  The use of
noninvasive
b.Thermal pain relief
Therapy(ice measures can
pack) increase the
release of
c. Distraction endorphins and
enhance the
therapeutic
effects of pain
relief
medications.
(Fundamentals
of Nursing by
d. Relaxation Kozier, Erb,
techniques Berman,
( deep Snyder, p.
breathing ) 1164)

 Promotes
comfort
e. Guided because it
Imagery produces
f. Music muscle
Therapy relaxation

2.3 Perform the  Stimulates


mentioned non- the nonpain
pharmacologic receptors.
measures to
3. After 3 hours of relieve pain  Reduces
nursing experienced by the perception 3. After 3 hours of
intervention the the client. of pain by nursing intervention
client will be able stimulating the the client was able
to report 2.4 Monitor descending to report diminished
diminished pain client’s response control system, pain through
through to pain relief resulting in pharmacologic
pharmacologic measures. If a pain fewer pain methods.
methods. measure is stimuli being
ineffective, transmitted to
encourage the the brain.
client to try it once  Regular
or twice before relaxation
abandoning it. In periods may ADEQUACY:
these help combat The time, skills,
circumstances, the fatigue and knowledge and
reassess the pain muscle tension resources were
and consider other that occur with adequate in
pain relief and increase carrying out the
measures. chronic pain. interventions.

EFFICIENCY:
DEPENDENT The interventions
3.1 Check the were done
medical order for effectively without
drug, dose, and any waste of time
frequency of the and resources
medication
prescribed. APPROPRIATENESS
 Follow-up The interventions
assessment is were appropriate to
essential to improve the client’s
determine the condition?
effectiveness of
3.2 Administer the pain relief ACCEPTABILITY
prescribed measures used The interventions
medication anti- and the need were acceptable to
inflammatory for any the client’s values,
medication to the change. . beliefs, customs.
client. (Maternal and
Child Nursing:
Care of the
Childbearing
and
Childrearing
family, by
Pillitteri, p. 558)

 Ensures
that the nurse
has the right
3.3 Evaluate the drug, right
effectiveness of route, right
the medication at dosage, right
regular, frequent client and right
intervals after frequency.
each (Fundamentals
administration of Nursing by
and especially Kozier, Erb,
after the initial Berman,
doses, also Snyder, p.
observing for any 1164)
signs and
symptoms of  One type of
untoward effects arthritis pain
(e.g. respiratory relievers are
depression, NSAIDs --
nausea and nonsteroidal
vomiting, dry anti-
mouth and inflammatory
constipation) drugs. These
are drugs that
reduce
inflammation
and relieve
pain.
Inflammation is
the body's
response to
irritation or
injury, and is
characterized
by redness,
warmth,
swelling, and
pain.

 Each
patient’s
response to the
pain experience
is unique, and
various dosages
and
combinations of
medications
may need to be
tried.(Nursing
Care Plan for
DRGs, p. 375)

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