Acute Pain Related To Hyper Secretion Of Gastric Juices As Evidenced By Yellowish Vomitus And Pain Scale Of 10/10

Assessment

Nursing diagnosis

August 19, 2009 09:30pm Subjective: Stated: “sobrang sakit ng tiyan ko noong isang araw , pabalik balik nga eh.” Objectives: • •

•

•

Pain scale of 10/10 Observe evidenced of pain Pulse rate of 90 beats per minute Facial mask

Scientific explanation Ulcer in gastric area

Acute pain related to hyper secretion of gastric juices as evidenced by yellowish vomitus and pain scale of 10/10

Release of chemical substances such as: Bradykinin

Planning Short term outcome: After 1 day of nursing intervention the client will be able to: • Report pain is relieved/contr olled

Bradykinin binds with prostaglandin and histamine

•

Follow prescribed pharmacologic al regimen

Transmit signal to spinal cord

•

Verbalize a non pharmacologic al method that provides relief.

Transmit to Medulla Oblongata Perception of pain

Discharge out come:

Reference: medical surgical nursing: 11th edition volume 1 Brunner and Suddarath

After 2 days of nursing intervention the client will be able to: • Demonstrate use of relaxation skills and divisional activities as indicated for individual

Intervention

Scientific rationale

independent: •

•

•

•

Determine client’s acceptable level of pain/control goal Provide comfort measures example: touch, repositioning, use of heat (cold packs), quite environment and calm activities. Instruct in/encourage use of relaxation techniques such as focused breathing, imaging, CDs/tapes Accepts

•

Varies with individual and situation.

Evaluation August 21, 2009 12:00pm Short term: Partially achieve

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To promote After 1 day of nursing non intervention the client pharmacologic can be able to: al pain management. • Follow prescribed pharmacologic al regimen •

•

To distract attention and reduce tension.

Verbalized non pharmacologic al methods that provides relief

Discharge outcome: •

Pain is a subjective experience and cannot be felt by others

Not Achieve After 2 days of nursing intervention the client cannot be able to:

situation. •

•

client’s description of pain. Acknowledge the pain experience of client’s response to pain.

Experiences no complications Remains free of pain between meals.

•

•

Demonstrate use of relaxation skills and divisional activities as indicated for individual situation.

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Experiences no complications

•

Remains free of pain between meals.

To promote accurate intake of drugs

Collaborative: •

Teach client about prescribe medications including name, dosage, frequency and possible side effects. Also identify medication such as aspirin that patient should be avoided.

References: NANDA 499-502 Medical surgical nursing handbook page: 615