SALVADOR, JHON KELVIN C. BSN 211 Cues Subjective Cues Masakit ang kaliwang tuhod ko.

. May arthritis kase ako eh said by the client. Sa 1 10 siguro mga 8. Kase masakit talaga said by the client Para bang kumikirot na masakit na di ko maipaliwanag tapos pag ginagalaw ko ayun sumasakit kaya nga di ko na ginagalaw minsan eh said by the client Kahapon nung naadmit ako dito sumasakit na sya, sinabi ko na nga sa doktor na masakit eh, bibigyan na lang daw ako ng gamot. Matagal Nursing Diagnosis Acute Pain related to inflammatory process as evidenced by verbal reports Analysis Activation of nociceptors or pain receptors Goals and Objectives Goal At the end of the shift, the client will be able to experience gradual reduction / relief / control of pain. Objectives After 4 minutes of discussion, the client will be able to identify 2 out of 3 importances of nonpharmacologic ways of relieving pain within 2 minutes. After 5 minutes of demonstration, the client will be able to demonstrate nonpharmacologic ways to reduce Nursing Intervention Independent Determine whether the client is experiencing pain at the time of the initial interview. If so, intervene at that time to provide pain relief. Assess and document the intensity, character, onset, duration, and aggravating and relieving factors of pain during the initial evaluation of the client. Rationale The initial assessment and documentation provide direction for the pain treatment plan. A comprehensive pain assessment includes all characteristics of the pain that the client can provide. The client's report of the pain is considered the single most reliable indicator of pain. (American Pain Society: Pain: current understanding of assessment, management and treatments, 2004, accessed March 26, 2007.) Single-item ratings of pain intensity are valid and reliable as Evaluation The client was able to experience reduction / relief / control of pain.

Inflammatory Process

Presence of underlying disease / condition (Arthritis)

The client was able to identify 2 out of 3 importances of nonpharmacologic ways of relieving pain within 2 minutes.

Pain on the affected area

Assess pain in a client by using a self-report 0 to

The client was able to demonstrate nonpharmacologic ways in relieving pain using deep breathing

na rin akong may rayuma, siguro mag teten years na said by the client Minsan nga lumilipat-lipat yung rayuma ko, sa kamay, sa kabilang tuhod tapos masakit talaga hindi ako makakilos. Said by the client. Dati umiinom sya ng Flanax pero parang hindi tumatalab tapos may nagsabi sa kanya na uminom ng Dexamethasone bay un? Ayun gumagana, nawawala daw ang sakit ng rayuma nya said by the clients daughter.

pain such as deep breathing exercise and massage within 3 minutes. After 8 hours of nursing intervention, the client will be able to follow instructions in taking his medications and comply with it. After 8 hours of series of nursing interventions, the client will be able to verbalize reduction / relief of pain

10 numerical pain rating scale, WongBaker FACES scale, or Faces Pain Scale.

measures of pain intensity. (Jensen MP: The validity and reliability of pain measures in adults with cancer, J Pain 4(1):5255, 2003.) Systematic ongoing assessment and documentation provide direction for the pain treatment plan; adjustments are based on the client's response. The client's report of pain is the single most reliable indicator of pain. (American Pain Society: Pain: current understanding of assessment, management and treatments, 2004,
accessed March 26, 2007.)

exercises and massaging.

Tell the client to report pain location, intensity, and quality when experiencing pain. Assess and document the intensity of pain and discomfort after any known pain -producing procedure, with each new report of pain, and at regular intervals

The client was able to follow instructions and took his medications on time.

The client verbalized relief / reduction of pain on the affected area.

Objective Cues Facial Grimace is present Affected knee is

Encourage verbalization of feelings about the pain.

Only the client can judge the level and distress of pain; pain management should be a team approach that

warm to touch Affected knee is swelling Positioning to avoid pain (Supine)

Encourage and assist client to do deep breathing exercises.

includes the client. Very few people lie about pain. (Medical-Surgical Nursing, 7th ed. By Black, Joyce M. and Jane Hokanson Hawks; p. 443) Deep breathing for relaxation is easy to learn and contributes to pain relief and/or reduction by reducing muscle tension and anxiety. . (MedicalSurgical Nursing, 7th ed. By Black, Joyce M. and Jane Hokanson Hawks; p. 479) Cold packs numb the sore area and reduce inflammation and swelling. They are especially good for joint pain caused by a flare. Heat relaxes your muscles and stimulates blood circulation. (http://www.arthritis

Using heat and cold treatments can reduce the pain and stiffness

Massage the affected area.

.org) Massage brings warmth and relaxation to the painful area. (http://www.arthritis .org)

Dependent: Administer medications as prescribed by the physician. Collaborative: Collaborate with the healthcare team (including the client and family) on an ongoing basis to determine an optimal pain control profile. Identify the most effective interventions and the medication administration routes most acceptable to the client and family.

Necessary for treatment of the underlying cause. (Nurses Pocket Guide, 9th ed. By Doenges, Marilynn, et.al., p.542) Success in pain control partially depends on the acceptability of the suggested intervention. Acceptability promotes compliance. (Ackley: Nursing Diagnosis Handbook, 8th Edition)