FAR EASTERN UNIVERSITY Institute of Nursing

Date: January 21, 2012 Concept: Leadership and Management Lauro NURSING CARE PLAN Diagnosis: Bacterial Meningitis CUES Subjective: The wife of the patient verbalized, alam ko nahihirapan na siya at nasasaktan. Kita naman kasi sa mukha niya eh. Kahit di na sya makausap at laging tulog uungol na lang siya pag may nararamdaman siyang masakit lalo na sa leeg at likod nya. Nursing Diagnosis Acute pain related to inflammation/irritation of the meninges with spasm of extensor muscles as evidence by facial grimace, restlessness, moaning and autonomic response. ANALYSIS Pain is an unpleasant and highly personal experience that may be imperceptible to others, while consuming all parts of the persons life. 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 Goal and Objectives Goal: After 8-10 hours of nursing intervention, the client will demonstrate relief of pain as evidenced by stable vital signs and absence of restlessness and Facial grimacing. INTERVENTION RATIONALE EVALUATION The patient was able to demonstrate relief of pain as evidenced by stable vital signs and absence of restlessness and Facial grimacing. Area: RMC-MW Clinical Instructor: Mam Jocelyn

Objectives: The patient manifested : -facial grimace -restlessness -moaning Vital Signs: Temp- 38.1 c PR- 72 RR- 20 BP- 150/100

injury or illness. Pain may also arise from emotional, psychological, cultural, or spiritual distress. Pain can be very difficult to explain, because it is unique to the individual; pain should be accepted as described by the sufferer. In my patients case, he suffers from bacterial meningitis which the common symptoms that can be the reason for the patients pain is neck stiffness, Back pain and muscle pains

Objectives: After 4-6 hours of nursing intervention the patients caregiver (wife) will be able to:

1. Maintain comfort and quit environmen t which decrease stimuli that may aggravate pain.

Create a quiet, non-disruptive environment with dim lights and Comfortable temperature when possible.

The client must feel comfortable trying a different approach to pain management.

1. The patient caregiver was able to maintain comfort and quit environme nt which decrease stimuli that may aggravate pain. 2. The patients caregiver was able to verbalize non pharmacol ogic methods that

2.

Verbalize non pharmacol ogic methods that provide relief.

Teach the use of non pharmacologic techniques (e.g., relaxation, music therapy, distraction, and massage) before, after, and if possible during

Relaxation techniques help reduce skeletal muscle tension, which will reduce the intensity of the pain

which are frequently present and may be very severe. Treatment of my patient may include analgesics to relieve fever and pain. Ref. Fundamentals of Nursing by Kozier 8th edition Page 1187 Pathan N et al 2003

painful activities; before pain occurs or increases; and along with other pain relief measures. Provide comfort measures (touch, repositioning, use of heat/cold packs, nurses presence) quiet environment and calm activities. Comfort and a quiet atmosphere promote a relaxed feeling and permit the client to focus on the relaxation technique rather than external distraction. The use of non-invasive pain relief measures can increase the re-lease of endorphins and enhance the therapeutic effects of pain relief medications.

provide relief.

3. Comply with prescribed pharmaco-logical regimen.

Check the medical order for drug, dose, and frequency of analgesic prescribed.

3. The patients caregiver was able to Comply with prescribed pharmacological regimen.

Determine analgesic selections (narcotic, nonnarcotic, or NSAID) based on type and severity of pain. Evaluate the effectiveness of analgesic at regular, frequent intervals after each administration and especially after the initial doses, also observing for any signs and symptoms of untoward effects.

Various types of pain (e.g., acute, chronic, neuropathic, nociceptive) require different analgesic approaches.

The analgesic dose may not be adequate to raise the clients pain threshold or may be causing intolerable or dangerous side effects or both.