Nursing Nursing Diagnosis Objectives Nursing Interventions Rationale for Evaluation

Problem with With Rationale Interventions

cues

Problem Pain Acute Pain related to After 1 hour of Assessment: a. Pain assessment is Goal partially
inflammatory process nursing important in determining met. After an
a. Investigate reports of pain, location,
Subjective and destruction of intervention, pain management needs hour of nursing
intensity. Note precipitating factors and
cues: “I feel the joint. client will be and effectiveness of the intervention,
nonverbal cues.
may joints are able to verbalize program. client
Rationale: Joint pain
very painful pain is relieved verbalized pain
is due to (Pain scale: 8/10, b. Duration of the pain
every time I from 8/10 to was controlled
prostaglandin reflects the severity of the
wake up in the 2/10.After 2 with pain scale
release, edema, and disease.
morning”, as hours of health Characteristic: Aching of 5/10.
synovial
verbalized by teaching client
inflammation and a2. Rests painful joints
the client. will be able to: Onset: Every mornings After 3 hours
destruction. and maintains neutral
of health
position. Use of splints
Identify 5 pain teaching, client
Pain Scale: Location: joints on both sides of the body can decrease pain and
management was able to
8/10 may reduce damage to
techniques such identify 5 out
the joint.
as biofeedback, b. Duration: 2-3 hours of 5 pain
Objective
guided-imagery, management
cues: guarding b2. Promotes relaxation
controlled Exacerbation: movements, or stress on techniques.
or protective and reduces muscle
breathing, joints
behavior, facial tension.
progressive
Client was able
grimacing
relaxation, and
Relief: Warm compresses on joints to perform 3
visualization. c2. Heat promotes muscle out of 5 pain
relaxation and mobility, management
Perform through Radiation: non-radiating
decreases pain, and techniques.
return relieves morning stiffness.
demonstration Associated s/s: tenderness, swelling,
the 5 pain warmth, stiffening
d2. Prevents fatigue and
management
joint stiffness. Stabilizes
techniques for
Independent: joint, decreasing joint
lifetime use.
movement and associated
pain.
a2. Place pillows, sandbags, trochanter rolls,
and splints.
b2. Provide gentle massage.
c2. Apply warm, moist compresses to
affected joints several times a day.
d2. Encourage frequent changes of position.
Assist client to move in bed, supporting
affected joints above and below.
e2. Medicate before planned activities.
Collaborative:
Administer medications as indicated.
Example medications:
1. celecoxib (Celebrex®) 100 mg/cap, 1 cap
BID, PO
2. anakinra (Kineret®) 100 mg/ml, 100 mg
OD via Sub
Health Teaching:
a3. Recommend firm mattress or bed board.
Elevate linens with bed cradle as needed.
b3. Recommend client to take warm bath or
shower on arising or at bedtime.
e2. Promotes relaxation,
reduces muscle tension,
facilitating participation in
therapy.
1. This medication inhibits
the enzyme COX-2. This
enzyme is required for the
synthesis of
prostaglandins, but is less
harmful to the stomach
and the kidneys. May take
celecoxib with or without
food intake.
2. This medication is
classified under Disease
Modifying Antirheumatic
Drug (DMARD). DMARD
blocks the destructive
effects of interleukin-1 on
cartilage and bone
resorption by inhibiting its
binding at specific tissue
at the receptor sites.
a3. Soft or sagging
mattress prevents
maintenance of proper
body alignment, placing
stress to affected joints.
b3. Heat promotes muscle
relaxation and mobility,
decreases pain, and
c3. Teach client the different kinds
diversional activities or pain management
techniques and how to perform them.
d3. (Biofeedback, guided-imagery,
controlled breathing, progressive relaxation,
and visualization)
Instruct client to follow pharmacologic
regimen as prescribed. Instruct them the
uses, dosage, time of use, contraindications,
interactions, and other medication related
concerns.
relieves morning stiffness.
c3. Refocuses attention,
provides stimulation, and
enhances self-esteem and
feelings of general well-
being.
d3. Teaching and
involving them with their
medical regimen increases
their understanding
regarding the prescribed
medications, thus
increasing their
pharmacological regimen
compliance.