Assessment ACUTE PAIN RELATED TO

S> masakit dito, tsaka dito pointing to incision site Pain rated as 6/10 characterized as sharp, radiating to the back pain. Aggravated upon sitting alleviated when lying still on bed. O> grimacing and guarding behaviour noted >vital signs taken as follows: BP: 120/80 PR: 132 RR: 25 T: 36.2 >limited movements observed >unable to perform ADLs independently >unable to sleep well >reduced interaction to other people

Explanation of the problem Surgical Procedure related to patients underlying condition (tube cholecystectomy) lead to tissue injury and breakdown. Chemical mediators are released such as prostaglandin, cyclooxygenase-2 and histamine which results to vasodilatation and irritation with nerve endings which then stimulates pain response which causes acute pain to the patient which can be a sign of bodys compensatory mechanism.

Goals and Objectives After 72 hours of nursing interventions the patient will be able to: a.) Have a total relief of pain b.) Able to sleep well

Interventions Dx. > Obtain clients assessment of pain to include location, characteristic, onset, frequency, quality, intensity, and precipitating factors. Reassess each time pain is reported.

Rationale > To rule out worsening of underlying condition/development of complications. Pain is a subjective experience and must be described by the client in order to plan effective treatment. Assists in differentiating cause of pain, and provides information about disease progression/resolution, development of complications, and effectiveness of interventions. > Observations may or may not be congruent with verbal reports or may be only indicator present when client is unable to verbalize. It is important to observe nonverbal cues of pain to anticipate what specific intervention is needed. > To identify contributing factors to longterm pain > To ensure continuity of interventions >To promote on pharmacological pain management. to reduce muscle tension > Non-pharmacological treatments promote relaxation and distract perception to pain. Non invasive measures can increase the release of endorphins and enhance the therapeutic effects of pain relief medications >Promotes rest, redirects attention, may enhance coping, also to enhance sleep > Personal factors can influence pain and pain tolerance. Factors that may be precipitating or augmenting pain should be reduced or eliminated to

Evaluation

After 8 hours of nursing interventions the patient will be able to: a.) Rate pain 4/10 b.) Absence of grimacing behaviour c.) Demonstrate non pharmacological ways on how to control or minimize pain

> Observe nonverbal cues of pain

> Assess conditions contributing to long-term pain > Note availability of SO Tx: > Demonstrate and encourage deep breathing exercises > Provide comfort measure (touch, repositioning every 2 hours), quiet environment, and calm activities.

>Promote bed rest by allowing patient to assume position of comfort. > Reduce or eliminate factors that precipitate or increase of patients pain experience