NCP Acute Pain

Assessment Nursing Rationale Desired Outcome Nursing Intervention Justification Evaluation
Diagnosis
Actual Abnormal Acute Pain After 8 hours of After 8 hours of nursing
Cues: related to Predisposing nursing intervention Independent and intervention the patient was able
tissue injury of Factors: the patient will be able Collaborative to:
 Patient the eye to: Interventions:
verbalized “Ga secondary to Unknown/
sakit akun mata, mechanical unidentified foreign 1.Follow prescribed -Administer analgesics as -To maintain 1.Goal met. Demonstrated good
ga hapdi kag daw trauma as object entered the pharmacological indicated such as acceptable level compliance to prescribed
may ma guwa” evidenced by eye causing irritation regimen Paracetamol 200mg/ of pain medication by taking it at the
inflammatory IVTT/ Q4º right schedule.
 Pain Scale of 7 process, facial
out of 10 grimacing, and -Monitor vital signs -Usually altered
(moderate to guarding Precipitating in acute pain
severe pain) behavior Factors:
 Tenderness, Definition:  Lifestyle

swelling and Unpleasant  Attitude 2.Demonstrate use of -Teach the use of -The use of 2. Goal partially met. Actively
redness of the sensory and  Parental relaxation skills and nonpharmacologic noninvasive pain participates in the relaxation
right eye emotional Guidance diversional activities techniques (e.g. relief measures techniques lead by the student
experience as indicated for relaxation, can increase the nurse as well as in other play
 Feeling of arising from  Age=12 (tend individual situation guided imagery, music release activities prepared based on pt’s
warmth actual or to be active) therapy, distraction, and of endorphins and developmental stage.
 under the eyes potential tissue  Gender- Male massage) before, enhance the
upon palpation damage or after, and if possible therapeutic
described in during painful activities; effects of pain
 Facial mask- terms of such Mechanical trauma before pain occurs or relief
grimacing and damage penetrating the orbital area increases; and along with medications.
crying (International causing tissue inflammation other pain relief
Association for measures.
 Exhibited the Study of
guarding Pain); sudden Release of pain and
behavior of the or slow onset inflammatory mediators
affected eye of any intensity (bradykinin, prostaglandin)
when being from mild to
inspected severe with an 3.Verbalize methods -Provide comfort -to provide non 3. Goal partially met.
anticipated or Nociceptors send signals to that provide relief measures such as change pharmacological Verbalizes specific positions
 Elevated WBC predictable end the brain of the intensity of in position, use of heat or pain management such as lying down in supine
level of 17.7 and a duration the pain by increasing the cold compress to the position and procedures that
(normal is 4.5 to of less than 6 frequency of signals sent to affected site alleviates pain such as play
13.5) 10^9/L months specialized areas within the activity and provides relief
CNS -Assess level of pain as -to provide due through medication
Source: of the moment care in alleviating administration.
Strengths: Doenges, M.E, the suffering of
 Good family et. Al. Nurse’s Pain signals travel through the patient
support Pocket Guide the spinal cord into the
Edition 11. dorsal horn
 Good compliance F.A. Davis -Instruct or encourage -to assist client to
to treatment Company. Pain signals are sent up, A- use of relaxation explore methods
regimen Philadelphia, delta nociceptor and C- exercises, such as for alleviation/
Pennsylvania. nociceptor fibers in the focused breathing control of pain
2008. ascending pathways to the
brain
-Encourage adequate rest -to prevent
facial mask, grimace, periods fatigue
feeling of warmth in the
eye, tenderness, guarding
behavior, increase vital
signs 4.Show a positive -Evaluate the -Research shows 5. Goal partially met.
behavior in the relief effectiveness of the pain that the most Demonstrated positive behavior
of present condition control measures used common reason towards present condition by
Acute Pain thorough ongoing for unrelieved participating in the treatment
assessment of pain pain is failure to regimen provided for him.
Source: Atlas of experience. routinely assess
Pathophysiology, 3rd Ed. pain and pain
Lippincott relief. Many
clients silently
tolerate pain if
not specifically
asked about it.
-Perform a -Pain is a
comprehensive subjective
assessment of pain to experience and
include location, must be described
characteristics, by the
onset/duration, client in order to
frequency, quality, plan effective
severity, and treatment to
precipitating or assess
aggravating factors precipitating
contributory
factors

NCP Acute Pain

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Assessment Nursing Rationale Desired Outcome Nursing Intervention Justification Evaluation

 Tenderness, Definition:  Lifestyle

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