Assessment Objective: - (+) DOB -Complains to chest pain on the thoracostomy site -Facial grimaces upon movement -Reports

of pain on the thoracostomy area, described as sharp provoked by breathing nonradiating, with a pain scale of 7 out of 10

Diagnosis Acute pain related to nflammation of the parietal pleura as evidenced by DOB, complains of chest pain and facial grimaces upon movement. Inference: Acute pain is pain that comes on quickly and usually lasts a short time. It serves as a warning of injury or illness. Acute pain can range from mild to severe and is often caused by an injury or sudden illness.

Planning Short Term: After 3-4 hours of nursing interventions, the patients pain will decrease from 7 to 3 as verbalized by the patient. Long Term: After 2-3 days of nursing interventions, the patient will demonstrate activities and behaviors that will prevent the recurrence of pain.

Intervention Independent: 1.Assess patient pain for intensity using a pain rating scale, for location and for precipitating factors. 2. Assess the response to medications every 5 minutes 3.Provide comfort measures. 4. Establish a quiet environment. 5. Elevate head of bed. 6. Monitor vital signs, especially pulse and blood pressure, every 5 minutes until pain subsides. 7. Teach patient relaxation techniques and how to use them to reduce stress.

Rationale 1.To identify intensity, precipitating factors and location to assist in accurate diagnosis. 2. Assessing response determines effectiveness of medication and whether further interventions are required. 3. To provide nonpharmacological pain management. 4. A quiet environment reduces the energy demands on the patient. 5. Elevation improves chest expansion and oxygenation. 6. Tachycardia and elevated blood pressure usually occur with angina and reflect compensatory mechanisms secondary to sympathetic

Evaluation Short Term: Patient shall have verbalized a decrease in pain from a scale of 7 to 3. Long Term: The patient shall have demonstrated activities and behaviors that will prevent the recurrence of pain

nervous system stimulation. 7. Anginal pain is often precipitated by emotional stress that can be relieved nonpharmacological measures such as relaxation.