Nursingcrib.com Nursing Care Plan Acute Pain (fronto-temporal Mass)

Cues

Subjective ◊ “Umiiyak sya palagi dahil sa pabalik-balik na sakit sa ulo nya gawa nung bukol sa likod ng kaliwang mata nia. ,” as verbalized by the father.

Nursing Diagnosis

◊ Acute Pain r/t fronto-temporal mass

Inference

Embryonal subclass of Rhabdomyosarcoma

affected striated muscle on head region

Objective

Nursing Intervention

Rationale

Short Term Goal

Independent

◊ After 30 minutes of nursing intervention, pain intensity will be minimized & comfort will be verbalized.

◊ Location, character, quality and severity of pain were evaluated.

◊ Pain limits chest excursion and thereby decreases ventilation.

◊ Maintained care in positioning the patient and turned every 2 hours.

◊ The patient who is comfortable and free of pain will be less likely to splint the chest while breathing.

◊ Incision area was assessed every 8 hours for redness, heat, induration, swelling and drainage.

◊ These signs indicate possible infection.

◊ Encouraged deep breathing exercises.

◊ This permits residual air in the pleural space to rise to upper portion of pleural space and be removed. This also provides comfort.

Objective ◊ c eyepatch OS, dry & intact

tumor development

◊ c mass OS ◊ c dressing L eyebrow, dry & intact

pressure, obstruction, pain

◊ (+) facial grimace ◊ irritable ◊ c pain on L fronto temporal ◊ V/S as follows: T= 36.8 °C P= 112 bpm R= 25 cpm

Dependent ◊ Administered analgesics as prescribed.

◊ Analgesics give pain relief on the part of the patient.

Evaluation

◊ After 30 minutes of nursing intervention, the goal is met through verbalization of being free from acute distress and feels much more comfortable. There is also no sign of incision infection.

Cues

Objective ◊ c eyepatch OS, dry & intact ◊ c mass OS ◊ c dressing L eyebrow, dry & intact ◊ c pale lips & nail beds over toes & fingers

Nursing Diagnosis

◊ Altered tissue perfusion r/t decreased Hgb concentration in blood AMB Hgb = 94 g/L

Inference

Embryonal subclass of Rhabdomyosarcoma

affected striated muscle on head region

tumor development

◊ Hgb level = 94g/L pressure, obstruction, pain

impaired blood circulation

Objective

Nursing Intervention

Rationale

Short Term Goal

Independent

◊ After 8 hours of nursing intervention, tissue perfusion will normalize & maintained.

◊ Vital signs monitored and recorded.

◊ This is for baseline comparison.

◊ Assessed circulation of the foot or hand. Checked for the peripheral pulses, color, capillary refill and temperature of fingers or toes.

◊ These characteristics of pulses, skin color, capillary refill time and temperature indicates impairment in blood circulation.

◊ Encouraged to perform active ROM exercises.

◊ This will promote venous return and better circulation.

◊ Advised to eat foods rich in iron such as organ meats, legumes & green leafy vegetables.

◊ Iron is a carrier of oxygen needed for cellular respiration.

Evaluation

◊ After 8 hours of nursing intervention, the goal is met through observation of pinkish lips & nail beds; and absence of other signs of circulatory impairment.