Ncp Acute Pain

Need/Nursing Diagnosis/Cues Need: Physiologic need Acute Pain related to spasm at upper extremities S-> “Magsakit ako bukton” as verbalized by the patient, with the pain scale of 9/10. O-> *Patient seen sitting on bed *patient shows weakness and evidence of pain *guarding behavior (restless) *distraction behavior *BP = 130/90mmHg *Self-focusing or narrowed focus

Objective After 6-8hrs of nursing intervention the patient will be able to: >Report pain is relieved/control led, with the pain scale of 3/10 from 9/10 > Verbalize understanding of condition. >verbalize method that provide relief >demonstrate use of relaxation skills and diversional activities

Scientific Analysis Acute pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (international association for the study of pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months. Source; Contemporary Medical Surgical Nursing, Daniels R., NosekL.,Nicoll., pp.992.

Nursing Intervention >Monitor vital signs

Rationale >Alterations from normal maybe signs of infection

>Perform an assessment of pain to include location, characteristics , onset/ duration, frequency, quality, severity, grimacing ( 0 – 10 scale)

-Indicates need for/ effectiveness of interventions and may signal development/ resolution of complications.

>Provide comfort measures, quiet environment and calm activities

-To promote non -pharmacological pain management

>Encourage diversional activities and relaxation techniques such as focused breathing and imaging

To distract attention and reduce tension

>Administer analgesics, as indicated, to maximum dosage, as needed

-To maintain “acceptable” level of pain

Evaluation