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Nursing Diagnosis Actual Abnormal Acute Pain related to Cues: tissue injury of Patient the eye verbalized Ga secondary

y to sakit akun mata, mechanical ga hapdi kag daw trauma as may ma guwa evidenced by inflammatory Pain Scale of 7 process, facial out of 10 grimacing, and (moderate to guarding severe pain) behavior Tenderness, swelling and redness of the right eye Feeling of warmth under the eyes upon palpation Facial maskgrimacing and crying Exhibited guarding behavior of the Definition: 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

Assessment

Rationale Predisposing Factors: Unknown/ unidentified foreign object entered the eye causing irritation

Desired Outcome After 8 hours of nursing intervention the patient will be able to: 1.Follow prescribed pharmacological regimen

Nursing Intervention Independent and Collaborative Interventions:

Justification

Evaluation After 8 hours of nursing intervention the patient was able to: 1.Goal met. Demonstrated good compliance to prescribed medication by taking it at the right schedule.

-Administer analgesics as -To maintain indicated such as acceptable level Paracetamol 200mg/ of pain IVTT/ Q4 -Monitor vital signs -Usually altered in acute pain

Precipitating Factors: Lifestyle Attitude Parental Guidance Age=12 (tend to be active) Gender- Male 2.Demonstrate use of relaxation skills and diversional activities as indicated for individual situation

Mechanical trauma penetrating the orbital area causing tissue inflammation Release of pain and inflammatory mediators

-Teach the use of nonpharmacologic techniques (e.g. relaxation, guided imagery, music therapy, distraction, and massage) before, after, and if possible during painful activities; before pain occurs or increases; and along with other pain relief measures.

-The use of noninvasive pain relief measures can increase the release of endorphins and enhance the therapeutic effects of pain relief medications.

2. Goal partially met. Actively participates in the relaxation techniques lead by the student nurse as well as in other play activities prepared based on pts developmental stage.

affected eye when being inspected Elevated WBC level of 17.7 (normal is 4.5 to 13.5) 10^9/L

of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months

(bradykinin, prostaglandin) Nociceptors send signals to the brain of the intensity of the pain by increasing the frequency of signals sent to specialized areas within the CNS Pain signals travel through the spinal cord into the dorsal horn Pain signals are sent up, Adelta nociceptor and Cnociceptor fibers in the ascending pathways to the brain facial mask, grimace, feeling of warmth in the eye, tenderness, guarding behavior, increase vital signs Acute Pain Source: Atlas of Pathophysiology, 3rd Ed. Lippincott -Instruct or encourage use of relaxation exercises, such as focused breathing -Encourage adequate rest periods 3.Verbalize methods that provide relief -Provide comfort measures such as change in position, use of heat or cold compress to the affected site -Assess level of pain as of the moment -to provide non pharmacological pain management 3. Goal partially met. Verbalizes specific positions such as lying down in supine position and procedures that alleviates pain such as play activity and provides relief through medication administration.

Source: Doenges, M.E, Strengths: Good family et. Al. Nurses Pocket Guide support Edition 11. Good compliance F.A. Davis to treatment Company. Philadelphia, regimen Pennsylvania. 2008.

-to provide due care in alleviating the suffering of the patient -to assist client to explore methods for alleviation/ control of pain -to prevent fatigue

4.Show a positive behavior in the relief of present condition

-Evaluate the effectiveness of the pain control measures used thorough ongoing assessment of pain experience.

-Research shows that the most common reason for unrelieved pain is failure to routinely assess pain and pain relief. Many

5. Goal partially met. Demonstrated positive behavior towards present condition by participating in the treatment regimen provided for him.

clients silently tolerate pain if not specifically asked about it. -Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, severity, and precipitating or aggravating factors -Pain is a subjective experience and must be described by the client in order to plan effective treatment to assess precipitating contributory factors

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