NCP-Pain1

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NURSING CARE PLAN: PAIN

Name of Patient: Montalban RizalAge: 45 years oldDiagnosis: Acute Pyelonephritis

CUESNURSING

DIAGNOSISANALYSIS/HEALTH

IMPLICATIONGOAL AND

OBJECTIVESNURSING

INTERVENTIONSRATIONALE EVALUATION

INTERACTIONMasakit ung dito(pertaining to thelower abdomen),tapos paggumagalaw akomasakit din.Minsan sa likod,tapos dito sa babang dibdib.- When asked todescribe theintensity of pain ona scale of 1-10, thepatient said its 6

OBSERVATIONSpatients facialexpressions showsigns of pain- guardingbehavior on thelower abdomen- patient looksrestless and weak

Acute pain relatedto acuteinflammation ofrenal tissues asmanifested bypatientsverbalization,behavior, andchanges in vitalsigns

IMMEDIATE CAUSEAcute inflammation ofrenal tissuesINTERMEDIATECAUSEAcute pyelonephritisROOT CAUSEStone formation

HEALTHIMPLICATIONGenitourinary pain isusually caused bydistension of someportion of the urinarytract because ofobstructed urine flowor inflammation andswelling of tissues.Severity of pain ofpain is related to thesudden onset ratherthan the extent ofdistension.Unrelived acute paincan affect thepulmonary,cardiovascular,gastrointestinal,endocrine, andimmune systems. The

GOALAfter 8 hours ofnursingintervention, theclient will be ableto reportrelief/control ofpain.

OBJECTIVES1) After 15-20minutes ofphysicalassessment, theclient will beassessed forprecipitating/contributingfactors of hispain.

1) Perform physicalassessment whichincludes locationand characteristicsof pain

a. Use painassessment scale toidentify intensity ofpain.

Pain is asubjectiveexperience andmust bedescribed by theclient in order toplan effectivetreatment.Kozier,Fundamentals ofNursing, 7th ed.,

p.1164

Provides baselinefor assessingchanges in painlevel andevaluatinginterventions.Smeltzer & Bare,Medical Surgical

1) Was the clientable to beassessed forprecipitating/contributing factorsof his pain after 15-20 minutes ofphysicalassessment?Yes __ No __If No, Why?

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MEASUREMENTBlood Pressure:150/90 up to160/90 mmHgRespiratory rate:

25 up to 28breaths per min

stress response(neuroendocrineresponse to stress)that occurs withtrauma also occurs

with other causes ofsevere pain. Thewidespread endocrine,immunologic, andinflammatory changesthat occur with stresscan have significantnegative effects. Thisis particularly harmfulin patientscompromised by age,

illness, or injury.Smeltzer & Bare,Medical SurgicalNursing, 10th ed.,

pp.218,1259

2) After 10-15minutes of

interaction, theclient will be able

b. Assess andrecord pain and its

characteristics:location, quality,frequency andduration.

c. Note cultural anddevelopmental

influences affectingpain response.

d. Monitor vitalsigns.

Discuss with theclient the importance

of eliminatingprecipitating factors

Nursing, 10th ed.,pp.245

Data assist inevaluating pain

and pain reliefand identifyingmultiple sourcesand types of pain.Smeltzer & Bare,Medical SurgicalNursing, 10th ed.,

pp.245

Each personexperiences and

expresses pain inan individualmanner using avariety of socialadaptationtechniques.Kozier,Fundamentals ofNursing, 7th ed.,

p.1164

Usually altered inacute pain.Doenges,Moorhouse,Geissler-Murr,Nurses PocketGuide, 9th ed.,

p.367

Personal factorscan influence

pain and paintolerance. Those

2) Was the clientable to verbalize

reduction ofprecipitating

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to verbalizereduction ofprecipitatingfactors of pain.

3) After 20-30minutes of

intervention, theclient will beprovided withnon-pharmacologicmeasures toreduce pain.

4) After 5 minutesof drug

such as fear,fatigue, anxiety, andstress.

a. Teach patient theuse of non-

pharmacologictechniques such asrelaxation, musictherapy ordistraction.

b. Encourageadequate restperiods.

AdministerDiclofenac

factors that maybe precipitating oraugmenting painshould bereduced oreliminated toenhance theoverall painmanagementprogram.Fundamentals ofNursing, 7th ed.,

p.1164

The use of non-invasive pain

relief measurescan increase therelease ofendorphins andenhance thetherapeuticeffects of painreliefmedications.Fundamentals ofNursing, 7th ed.,

p.1164

To preventfatigue.Doenges,Moorhouse,Geissler-Murr,Nurses PocketGuide, 9th ed.,

p.367

Analgesics aremore effective if

factors of pain after10-15 minutes ofinteraction?Yes __ No __If No, Why?

3) Was the clientable to be provided

with non-pharmacologicmeasures toreduce pain after20-30 minutes ofintervention?Yes __ No __If No, Why?

4) Was the client

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administration,the client will begiven analgesicsas prescribed bythe physician.

(Voltaren) 50mg 1tab PRN for pain asprescribed by thephysician.

a. Evaluate theeffectiveness ofanalgesic at regularfrequent intervalsafter eachadministration.

b. Instruct patientand family aboutpotential side effectsof analgesics andtheir prevention andmanagement.

administeredearly in paincycle.Simultaneous useof analgesics thatwork on differentportions of thenociceptivesystem willprovide greaterpain relief withfewer sideeffects.Smeltzer & Bare,Medical SurgicalNursing, 10th ed.,

pp.245

The analgesicdose may not beadequate to raisethe clients painthreshold or maybe causingintolerable ordangerous sideeffects or both.Fundamentals ofNursing, 7th ed.,

p.1164

able to be givenanalgesics asprescribed by thephysician after 5minutes of drugadministration?Yes __ No __If No, Why?

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NCP-Pain1