Nursing diagnosis: acute Pain related to insertion of catheter through abdominal wall, catheter irritation, improper catheter placement, irritation, infection within the peritoneal cavity, infusion of cold or acidic dialysate, abdominal distention, rapid infusion of dialysate
Possibly evidenced by
Reports of pain
Self-focusing
Guarding, distraction behaviors, restlessness
Desired Outcomes/Evaluation Criteria—Client Will
Pain Control
Verbalize decrease of pain and discomfort.
Demonstrate relaxed posture and facial expression; be able to sleep and rest appropriately.
Nursing intervention with rationale:
1. Investigate client’s reports of pain; note intensity (0 to 10), location, and precipitating factors.
Rationale: Assists in identification of source of pain and appropriate interventions.
2. Explain that initial discomfort usually subsides after the first few exchanges.
Rationale: Information may reduce anxiety and promote relaxation during procedure.
3. Monitor for pain that begins during inflow and continues during equilibration phase. Slow infusion rate, as indicated.
Rationale: Pain will occur if acidic dialysate causes chemical irritation of peritoneal membrane.
4. Note reports of discomfort that are most pronounced near the end of inflow, and instill no more than 2,000 mL of solution at a single time.
Rationale: Likely the result of abdominal distention from dialysate. Amount of infusion may have to be decreased initially.
5. Prevent air from entering peritoneal cavity during infusion. Note report of pain in area of shoulder blade.
Rationale: Inadvertent introduction of air into the abdomen irritates the diaphragm and results in referred pain to shoulder blade. This type of discomfort may also be reported during initiation of therapy or during infusions and usually is related to stretching or irritation of the diaphragm with abdominal distention. Smaller exchange volumes may be required until client adjusts.
6. Elevate head of bed at intervals. Turn client from side to side. Provide back care and tissue massage.
Rationale: Position changes and gentle massage may relieve abdominal and general muscle discomfort.
7. Warm dialysate to body temperature before infusing.
Rationale: Warming the solution increases the rate of urea removal by dilating peritoneal vessels. Cold dialysate causes vasoconstriction, which can cause discomfort and excessively lower the core body temperature, precipitating cardiac arrest.
8. Monitor for severe or continuous abdominal pain and temperature elevation, especially after dialysis has been discontinued.
Rationale: May indicate developing peritonitis.
9. Encourage use of relaxation techniques, such as deepbreathing exercises, guided imagery, and visualization. Provide diversional activities.
Rationale: Redirects attention and promotes sense of control.
10. Add sodium hydroxide to dialysate, if indicated.
Rationale: Occasionally used to alter pH if client is not tolerating acidic dialysate.
Showing posts with label Acute Pain. Show all posts
Showing posts with label Acute Pain. Show all posts
Friday, June 3, 2011
Thursday, May 19, 2011
Acute Pain | Nursing Diagnosis for Leukemia
Nursing diagnosis: Acute pain related to physical agents—enlarged organs and lymph nodes, bone marrow packed with leukemic cells, chemical agents—antileukemic treatments, psychological manifestations—anxiety, fear
Possibly evidenced by
Reports of pain—bone, nerve, headaches, and so forth
Guarding or distraction behaviors, facial grimacing, alteration in muscle tone
Autonomic responses
Desired Outcomes/Evaluation Criteria—Client Will
Pain Level
Report pain is relieved or controlled.
Appear relaxed and able to sleep and rest appropriately.
Pain Control
Demonstrate behaviors to manage pain.
Nursing intervention with rationale:
1. Investigate reports of pain. Note changes in degree (use scale of 0 to 10) and site.
Rationale: Helpful in assessing need for intervention and may indicate developing complications.
2. Monitor vital signs and note nonverbal cues, such as muscle tension and restlessness.
Rationale: May be useful in evaluating verbal comments and effectiveness of interventions.
3. Provide quiet environment and reduce stressful stimuli: noise, lighting, and constant interruptions.
Rationale: Promotes rest and enhances coping abilities.
4. Place in position of comfort, and support joints and extremities with pillows and other padding.
Rationale: May decrease associated bone and joint discomfort.
5. Reposition periodically and provide or assist with gentle range-of-motion (ROM) exercises.
Rationale: Improves tissue circulation and joint mobility.
6. Provide comfort measures, such as massage, cool packs, and psychological support, including encouragement and presence, as appropriate.
Rationale: Enhances effects of medication.
7. Review and promote client’s own comfort interventions— position and physical activity or nonactivity.
Rationale: Successful management of pain requires client involvement. Use of effective techniques provides positive reinforcement, promotes sense of control, and prepares client for interventions to be used after discharge.
8. Evaluate and support client’s coping mechanisms.
Rationale: Using own learned perceptions and behaviors to manage pain can help client cope more effectively.
9. Encourage use of stress management techniques, such as deep-breathing exercises, guided imagery, visualization, and therapeutic touch.
Rationale: Facilitates relaxation, augments pharmacological therapy, and enhances coping abilities.
10. Assist with or provide diversional activities and relaxation techniques.
Rationale: Helps with pain management by redirecting attention.
Possibly evidenced by
Reports of pain—bone, nerve, headaches, and so forth
Guarding or distraction behaviors, facial grimacing, alteration in muscle tone
Autonomic responses
Desired Outcomes/Evaluation Criteria—Client Will
Pain Level
Report pain is relieved or controlled.
Appear relaxed and able to sleep and rest appropriately.
Pain Control
Demonstrate behaviors to manage pain.
Nursing intervention with rationale:
1. Investigate reports of pain. Note changes in degree (use scale of 0 to 10) and site.
Rationale: Helpful in assessing need for intervention and may indicate developing complications.
2. Monitor vital signs and note nonverbal cues, such as muscle tension and restlessness.
Rationale: May be useful in evaluating verbal comments and effectiveness of interventions.
3. Provide quiet environment and reduce stressful stimuli: noise, lighting, and constant interruptions.
Rationale: Promotes rest and enhances coping abilities.
4. Place in position of comfort, and support joints and extremities with pillows and other padding.
Rationale: May decrease associated bone and joint discomfort.
5. Reposition periodically and provide or assist with gentle range-of-motion (ROM) exercises.
Rationale: Improves tissue circulation and joint mobility.
6. Provide comfort measures, such as massage, cool packs, and psychological support, including encouragement and presence, as appropriate.
Rationale: Enhances effects of medication.
7. Review and promote client’s own comfort interventions— position and physical activity or nonactivity.
Rationale: Successful management of pain requires client involvement. Use of effective techniques provides positive reinforcement, promotes sense of control, and prepares client for interventions to be used after discharge.
8. Evaluate and support client’s coping mechanisms.
Rationale: Using own learned perceptions and behaviors to manage pain can help client cope more effectively.
9. Encourage use of stress management techniques, such as deep-breathing exercises, guided imagery, visualization, and therapeutic touch.
Rationale: Facilitates relaxation, augments pharmacological therapy, and enhances coping abilities.
10. Assist with or provide diversional activities and relaxation techniques.
Rationale: Helps with pain management by redirecting attention.
Monday, May 16, 2011
Acute/Chronic Pain | Nursing Diagnosis for Sickle Cell Crisis
Nursing diagnosis: acute/chronic pain related to intravascular sickling with localized stasis, occlusion, infarction, and necrosis, activation of pain fibers due to deprivation of oxygen and nutrients, accumulation of noxious metabolites
Possibly evidenced by
Localized, migratory, or more generalized pain, described as throbbing, gnawing, or severe and incapacitating; affecting peripheral extremities, bones, joints, back, abdomen, or head, with headaches recurrent and transient
Decreased ROM, guarding of the affected areas
Facial grimacing, narrowed or self-focus
Desired Outcomes/Evaluation Criteria—Client Will
Pain Level
Verbalize relief or control of pain.
Demonstrate relaxed body posture, freedom of movement, and ability to sleep and rest appropriately.
Nursing intervention with rationale:
1. Assess reports of pain, including location, duration, and intensity (scale of 0 to 10). Have client help differentiate current pain from typical or usual pain problems.
Rationale: Vaso-occlusive pain is the most common manifestation of sickle cell crises, where sickling potentiates cellular hypoxia, resulting in severe pain. Typically, pain occurs deep in the bones and muscles of back, ribs, and limbs and lasts 5 to 7 days. However, client may also have acute pain from another cause (ulcers, appendicitis), chronic pain from sickle cell damage (usually bone pain that is present daily), chronic pain from other causes (old injuries, arthritis), and chronic nerve pain caused by damage from sickle cell blockage or other conditions, such as diabetes.
2. Observe nonverbal pain cues, such as gait disturbances, body positioning, reluctance to move, facial expressions; and physiological manifestations of acute pain—elevated BP, tachycardia, and increased respiratory rate. Explore discrepancies between verbal and nonverbal cues.
Rationale: Nonverbal cues may aid in evaluation of pain and effectiveness of therapy. Pain is unique to each client; therefore, one may encounter varying descriptions because of individualized perceptions.
3. Discuss with the client/SO what pain relief measures were effective in the past.
Rationale: Involves client/SO in care and allows for identification of remedies that have already been found to relieve pain. Helpful in establishing individualized treatment needs.
4. Explore alternative pain relief measures, such as relaxation techniques, biofeedback, yoga, meditation, and distraction—visual, auditory, tactile, kinesthetic, guided imagery, and breathing techniques.
Rationale: Cognitive-behavioral interventions may reduce reliance on pharmacological therapy and enhance client’s sense of control.
5. Provide support for and carefully position affected extremities.
Rationale: Reduces edema, discomfort, and risk of injury, especially if osteomyelitis is present.
6. Apply local massage gently to affected areas.
Rationale: Helps reduce muscle tension.
7. Apply warm, moist compresses to affected joints or other painful areas. Avoid use of ice or cold compresses.
Rationale: Warmth causes vasodilation and increases circulation to hypoxic areas. Cold causes vasoconstriction and compounds the crisis.
8. Administer medications, as indicated, for example: opioids, such as continuous infusion or around-the-clock morphine (Astramorph, Duramorph), hydromorphone (Dilaudid), and nalbuphine (Nubain); long-acting opiate combinations, such as morphine (MS Contin) and oxycodone (Oxycontin); nonopioid analgesics, such as acetaminophen (Tylenol); oral opiate combination analgesics, such as acetaminophen with codeine (Tylenol No. 3) and hydrocodone (Vicodin); and antiseizure medications, such as gabapentin (Neurontin).
Rationale: Various types of analgesics are needed to manage different types of pain. Opioids are the mainstay of pain control during crisis and are usually administered via patientcontrolled analgesia (PCA). Acetaminophen can be used for control of headache, pain, and fever. Aspirin should be avoided because it alters blood pH and can make cells sickle more easily. Note: Meperidine (Demerol) should not be used because its metabolite, normeperidine, can cause central nervous system (CNS) excitation—anxiety, tremors, and seizures.
9. Consult with or refer to physical therapy.
Rationale: Determines and provides appropriate therapies, such as massage, heat therapies, and guided exercise.
10. Administer and monitor RBC transfusion.
Rationale: Although transfusion does not halt the pain in an acute crisis, frequency of painful crises may be reduced by regular partial exchange transfusions to maintain population of normal RBCs.
Possibly evidenced by
Localized, migratory, or more generalized pain, described as throbbing, gnawing, or severe and incapacitating; affecting peripheral extremities, bones, joints, back, abdomen, or head, with headaches recurrent and transient
Decreased ROM, guarding of the affected areas
Facial grimacing, narrowed or self-focus
Desired Outcomes/Evaluation Criteria—Client Will
Pain Level
Verbalize relief or control of pain.
Demonstrate relaxed body posture, freedom of movement, and ability to sleep and rest appropriately.
Nursing intervention with rationale:
1. Assess reports of pain, including location, duration, and intensity (scale of 0 to 10). Have client help differentiate current pain from typical or usual pain problems.
Rationale: Vaso-occlusive pain is the most common manifestation of sickle cell crises, where sickling potentiates cellular hypoxia, resulting in severe pain. Typically, pain occurs deep in the bones and muscles of back, ribs, and limbs and lasts 5 to 7 days. However, client may also have acute pain from another cause (ulcers, appendicitis), chronic pain from sickle cell damage (usually bone pain that is present daily), chronic pain from other causes (old injuries, arthritis), and chronic nerve pain caused by damage from sickle cell blockage or other conditions, such as diabetes.
2. Observe nonverbal pain cues, such as gait disturbances, body positioning, reluctance to move, facial expressions; and physiological manifestations of acute pain—elevated BP, tachycardia, and increased respiratory rate. Explore discrepancies between verbal and nonverbal cues.
Rationale: Nonverbal cues may aid in evaluation of pain and effectiveness of therapy. Pain is unique to each client; therefore, one may encounter varying descriptions because of individualized perceptions.
3. Discuss with the client/SO what pain relief measures were effective in the past.
Rationale: Involves client/SO in care and allows for identification of remedies that have already been found to relieve pain. Helpful in establishing individualized treatment needs.
4. Explore alternative pain relief measures, such as relaxation techniques, biofeedback, yoga, meditation, and distraction—visual, auditory, tactile, kinesthetic, guided imagery, and breathing techniques.
Rationale: Cognitive-behavioral interventions may reduce reliance on pharmacological therapy and enhance client’s sense of control.
5. Provide support for and carefully position affected extremities.
Rationale: Reduces edema, discomfort, and risk of injury, especially if osteomyelitis is present.
6. Apply local massage gently to affected areas.
Rationale: Helps reduce muscle tension.
7. Apply warm, moist compresses to affected joints or other painful areas. Avoid use of ice or cold compresses.
Rationale: Warmth causes vasodilation and increases circulation to hypoxic areas. Cold causes vasoconstriction and compounds the crisis.
8. Administer medications, as indicated, for example: opioids, such as continuous infusion or around-the-clock morphine (Astramorph, Duramorph), hydromorphone (Dilaudid), and nalbuphine (Nubain); long-acting opiate combinations, such as morphine (MS Contin) and oxycodone (Oxycontin); nonopioid analgesics, such as acetaminophen (Tylenol); oral opiate combination analgesics, such as acetaminophen with codeine (Tylenol No. 3) and hydrocodone (Vicodin); and antiseizure medications, such as gabapentin (Neurontin).
Rationale: Various types of analgesics are needed to manage different types of pain. Opioids are the mainstay of pain control during crisis and are usually administered via patientcontrolled analgesia (PCA). Acetaminophen can be used for control of headache, pain, and fever. Aspirin should be avoided because it alters blood pH and can make cells sickle more easily. Note: Meperidine (Demerol) should not be used because its metabolite, normeperidine, can cause central nervous system (CNS) excitation—anxiety, tremors, and seizures.
9. Consult with or refer to physical therapy.
Rationale: Determines and provides appropriate therapies, such as massage, heat therapies, and guided exercise.
10. Administer and monitor RBC transfusion.
Rationale: Although transfusion does not halt the pain in an acute crisis, frequency of painful crises may be reduced by regular partial exchange transfusions to maintain population of normal RBCs.
Sunday, May 1, 2011
Acute Pain | Nursing Care Plan for Pancreatitis
Nursing diagnosis: acute Pain related to Obstruction of pancreatic, biliary ducts, Chemical contamination of peritoneal surfaces by pancreatic exudate, autodigestion of pancreas, Extension of inflammation to the retroperitoneal nerve plexus
Possibly evidenced by
Reports of pain
Self-focusing, grimacing, distraction or guarding behaviors
Autonomic responses, alteration in muscle tone
Desired Outcomes/Evaluation Criteria—Client Will
Pain Control
Report pain is relieved or controlled.
Follow prescribed therapeutic regimen.
Demonstrate use of methods that provide relief.
Nursing intervention with rationale:
1. Investigate verbal reports of pain, noting specific location and intensity (0 to 10 scale). Note factors that aggravate and relieve pain.
Rationale: Pain is often diffuse, severe, and unrelenting in acute or hemorrhagic pancreatitis. Severe pain is often the major symptom in client with chronic pancreatitis. Isolated pain in the right upper quadrant (RUQ) reflects involvement of the head of the pancreas. Pain in the left upper quadrant (LUQ) suggests involvement of the pancreatic tail. Localized pain may indicate development of pseudocysts or abscesses.
2. Maintain bedrest during acute attack and provide quiet, restful environment.
Rationale: Decreases stimulation of pancreatic secretions, thereby reducing pain.
3. Promote position of comfort, such as on one side with knees flexed or sitting up and leaning forward.
Rationale: Reduces abdominal pressure and tension, providing some measure of comfort and pain relief. Note: Supine position often increases pain.
4. Provide alternative comfort measures including repositioning and back rub,and quiet diversional activities such as TV or radio. Encourage relaxation techniques, such as guided imagery and visualization.
Rationale: Promotes relaxation and enables client to refocus attention; may enhance coping.
5. Keep environment free of food odors.
Rationale: Sensory stimulation can activate pancreatic enzymes, increasing pain.
6. Administer intravenous (IV) analgesics in timely manner, and in smaller, more frequent doses, during acute episode. Consider use of patient-controlled analgesia (PCA), if appropriate.
Rationale: Severe or prolonged pain can aggravate shock and is more difficult to relieve, requiring larger doses of medication, which can mask underlying problems and complications and may contribute to respiratory depression.
7. Maintain meticulous skin care, especially in presence of draining abdominal wall fistulas.
Rationale: Pancreatic enzymes can digest the skin and tissues of the abdominal wall, creating abscesses and ulceration.
8. Administer medication, as indicated, for example: Opioid analgesics, such as meperidine (Demerol), morphine sulfate, and tramadol (Ultram)
Rationale: Meperidine is usually effective in relieving pain and may be preferred over morphine, which may have a side effect of biliary-pancreatic spasms. Paravertebral block has been used to achieve prolonged pain control. Note: Pain in clients who have recurrent or chronic pancreatitis episodes may be more difficult to manage because they may develop tolerance to normal doses of the opioids given for pain control.
9. Sedatives such as diazepam (Valium) and antispasmodics such as atropine
Rationale: Potentiate action of opioid to promote rest and to reduce ductal spasm, thereby reducing metabolic needs and enzyme secretions.
10. Histamine blockers, such as lansoprazole (Prevacid), cimetidine (Tagamet), ranitidine (Zantac), and famotidine (Pepcid)
Rationale: Decreasing production of hydrochloric acid inhibits pancreatic enzyme activity and associated pain.
Possibly evidenced by
Reports of pain
Self-focusing, grimacing, distraction or guarding behaviors
Autonomic responses, alteration in muscle tone
Desired Outcomes/Evaluation Criteria—Client Will
Pain Control
Report pain is relieved or controlled.
Follow prescribed therapeutic regimen.
Demonstrate use of methods that provide relief.
Nursing intervention with rationale:
1. Investigate verbal reports of pain, noting specific location and intensity (0 to 10 scale). Note factors that aggravate and relieve pain.
Rationale: Pain is often diffuse, severe, and unrelenting in acute or hemorrhagic pancreatitis. Severe pain is often the major symptom in client with chronic pancreatitis. Isolated pain in the right upper quadrant (RUQ) reflects involvement of the head of the pancreas. Pain in the left upper quadrant (LUQ) suggests involvement of the pancreatic tail. Localized pain may indicate development of pseudocysts or abscesses.
2. Maintain bedrest during acute attack and provide quiet, restful environment.
Rationale: Decreases stimulation of pancreatic secretions, thereby reducing pain.
3. Promote position of comfort, such as on one side with knees flexed or sitting up and leaning forward.
Rationale: Reduces abdominal pressure and tension, providing some measure of comfort and pain relief. Note: Supine position often increases pain.
4. Provide alternative comfort measures including repositioning and back rub,and quiet diversional activities such as TV or radio. Encourage relaxation techniques, such as guided imagery and visualization.
Rationale: Promotes relaxation and enables client to refocus attention; may enhance coping.
5. Keep environment free of food odors.
Rationale: Sensory stimulation can activate pancreatic enzymes, increasing pain.
6. Administer intravenous (IV) analgesics in timely manner, and in smaller, more frequent doses, during acute episode. Consider use of patient-controlled analgesia (PCA), if appropriate.
Rationale: Severe or prolonged pain can aggravate shock and is more difficult to relieve, requiring larger doses of medication, which can mask underlying problems and complications and may contribute to respiratory depression.
7. Maintain meticulous skin care, especially in presence of draining abdominal wall fistulas.
Rationale: Pancreatic enzymes can digest the skin and tissues of the abdominal wall, creating abscesses and ulceration.
8. Administer medication, as indicated, for example: Opioid analgesics, such as meperidine (Demerol), morphine sulfate, and tramadol (Ultram)
Rationale: Meperidine is usually effective in relieving pain and may be preferred over morphine, which may have a side effect of biliary-pancreatic spasms. Paravertebral block has been used to achieve prolonged pain control. Note: Pain in clients who have recurrent or chronic pancreatitis episodes may be more difficult to manage because they may develop tolerance to normal doses of the opioids given for pain control.
9. Sedatives such as diazepam (Valium) and antispasmodics such as atropine
Rationale: Potentiate action of opioid to promote rest and to reduce ductal spasm, thereby reducing metabolic needs and enzyme secretions.
10. Histamine blockers, such as lansoprazole (Prevacid), cimetidine (Tagamet), ranitidine (Zantac), and famotidine (Pepcid)
Rationale: Decreasing production of hydrochloric acid inhibits pancreatic enzyme activity and associated pain.
Wednesday, April 13, 2011
Acute Pain | Nursing Care Plan for Thyroidectomy
Nursing diagnosis: acute Pain related to Surgical interruption and manipulation of tissues and muscles, Postoperative edema
Possibly evidenced by
Reports of pain
Narrowed focus, guarding behavior, restlessness
Autonomic responses
Desired Outcomes/Evaluation Criteria—Client Will
Pain Control
Report pain is relieved and controlled.
Demonstrate use of relaxation skills and diversional activities appropriate to situation.
Nursing intervention with rationale:
1. Assess verbal reports and nonverbal cues of pain, noting location, intensity (0 to 10 scale), and duration.
Rationale: Useful in evaluating pain, choice of interventions, and effectiveness of therapy.
2. Place in semi-Fowler’s position and support head and neck in neutral position with sandbags or small pillows as required in immediate postoperative phase. Instruct client to use hands to support neck during movement and to avoid hyperextension of neck.
Rationale: Prevents hyperextension of the neck and protects integrity of the suture line. Movement restriction is imposed for only a few hours postoperatively to prevent stress on the suture line and reduce muscle tension. Gentle flexing and stretching is then permitted according to pain tolerance to help prevent neck soreness.
3. Keep call light and frequently needed items within easy reach.
Rationale: Limits stretching and muscle strain in operative area.
4. Give cool liquids or soft foods, such as ice cream or popsicles.
Rationale: Although both may be soothing to sore throat, soft foods may be better tolerated than liquids if client experiences difficulty swallowing.
5. Encourage client to use relaxation techniques, such as guided imagery, soft music, and progressive relaxation.
Rationale: Helps refocus attention and assists client to manage pain and discomfort more effectively.
6. Administer analgesics and throat sprays and lozenges, as necessary.
Rationale: Reduces pain and discomfort; enhances rest.
7. Provide ice collar, if indicated.
Rationale: Reduces tissue edema and decreases perception of pain.
Possibly evidenced by
Reports of pain
Narrowed focus, guarding behavior, restlessness
Autonomic responses
Desired Outcomes/Evaluation Criteria—Client Will
Pain Control
Report pain is relieved and controlled.
Demonstrate use of relaxation skills and diversional activities appropriate to situation.
Nursing intervention with rationale:
1. Assess verbal reports and nonverbal cues of pain, noting location, intensity (0 to 10 scale), and duration.
Rationale: Useful in evaluating pain, choice of interventions, and effectiveness of therapy.
2. Place in semi-Fowler’s position and support head and neck in neutral position with sandbags or small pillows as required in immediate postoperative phase. Instruct client to use hands to support neck during movement and to avoid hyperextension of neck.
Rationale: Prevents hyperextension of the neck and protects integrity of the suture line. Movement restriction is imposed for only a few hours postoperatively to prevent stress on the suture line and reduce muscle tension. Gentle flexing and stretching is then permitted according to pain tolerance to help prevent neck soreness.
3. Keep call light and frequently needed items within easy reach.
Rationale: Limits stretching and muscle strain in operative area.
4. Give cool liquids or soft foods, such as ice cream or popsicles.
Rationale: Although both may be soothing to sore throat, soft foods may be better tolerated than liquids if client experiences difficulty swallowing.
5. Encourage client to use relaxation techniques, such as guided imagery, soft music, and progressive relaxation.
Rationale: Helps refocus attention and assists client to manage pain and discomfort more effectively.
6. Administer analgesics and throat sprays and lozenges, as necessary.
Rationale: Reduces pain and discomfort; enhances rest.
7. Provide ice collar, if indicated.
Rationale: Reduces tissue edema and decreases perception of pain.
Saturday, April 2, 2011
Nursing Care Plan | NCP Total Hip Replacement
Nursing diagnosis: acute Pain related to Injuring agents—biological, physical, psychological—muscle spasms, surgical procedure, preexisting chronic joint diseases, elderly age, anxiety
Possibly evidenced by
Reports of pain; distraction, guarding behaviors
Narrowed focus, self-focusing
Alteration in muscle tone; autonomic responses
Desired Outcomes/Evaluation Criteria—Client Will
Pain Level
Report pain relieved or controlled.
Appear relaxed, able to rest or sleep appropriately.
Pain Control
Demonstrate use of relaxation skills and diversional activities, as indicated by individual situation.
Nursing intervention with rationale:
1. Perform comprehensive assessment of pain, noting intensity (scale of 0–10), duration, and location. Determine if pain is at operative or different site, associated with ROM or weightbearing, associated with vascular compromise or fever.
Rationale: Provides information on which to base and monitor effectiveness of interventions.
2. Maintain proper position of operated extremity.
Rationale: Reduces muscle spasm and undue tension on new prosthesis and surrounding tissues.
3. Provide comfort measures—frequent repositioning, back rub—and diversional activities. Encourage stress management techniques, such as progressive relaxation, guided imagery, visualization, and meditation. Provide Therapeutic Touch, as appropriate.
Rationale: Reduces muscle tension, refocuses attention, promotes sense of control, and may enhance coping abilities in the management of discomfort or pain, which can persist for an extended period.
4. Medicate on a regular schedule and before activities or procedures.
Rationale: Reduces muscle tension, improves comfort, and facilitates participation.
5. Investigate reports of sudden, severe joint pain with muscle spasms and changes in joint mobility, or sudden, severe chest pain with dyspnea and restlessness.
Rationale: Early recognition of developing problems, such as dislocation of prosthesis or blood or fat pulmonary emboli, provides opportunity for prompt intervention and prevention of more serious complications.
6. Administer medications as indicated, around the clock, such as: Opioids—instruct in and monitor use of patient-controlled analgesia (PCA), epidural administration, and/or pain ball
Rationale: Relieves surgical pain and reduces muscle tension and spasm, which contribute to overall discomfort. Opioid infusion (including epidural) may be given during the first 24 to 48 hours. The ON-Q PainBuster® ball provides continuous infusion of local anesthetic directly into surgical site for up to 5 days, thus decreasing need for opioids, and allows for earlier ambulation than epidural administration.
7. Analgesics, such as, oxycodone (Percocet), hycodone and acetaminophen (Vicodin), and muscle relaxants
Rationale: Oral analgesics are added to pain management program as the client progresses. Note: Use of ketorolac (Toradol) or other nonsteroidal anti-inflammatory drug (NSAID) is contraindicated when client is receiving enoxaparin (Lovenox) therapy.
8. Apply ice packs, as indicated.
Rationale: Promotes vasoconstriction to reduce bleeding and tissue edema in surgical area and lessens perception of discomfort.
9. Initiate and maintain extremity mobilization, such as, ambulation, physical therapy, exerciser, or continuous passive motion (CPM) device.
Rationale: Increases circulation to affected muscles. Minimizes joint stiffness; relieves muscle spasms related to disuse.
Possibly evidenced by
Reports of pain; distraction, guarding behaviors
Narrowed focus, self-focusing
Alteration in muscle tone; autonomic responses
Desired Outcomes/Evaluation Criteria—Client Will
Pain Level
Report pain relieved or controlled.
Appear relaxed, able to rest or sleep appropriately.
Pain Control
Demonstrate use of relaxation skills and diversional activities, as indicated by individual situation.
Nursing intervention with rationale:
1. Perform comprehensive assessment of pain, noting intensity (scale of 0–10), duration, and location. Determine if pain is at operative or different site, associated with ROM or weightbearing, associated with vascular compromise or fever.
Rationale: Provides information on which to base and monitor effectiveness of interventions.
2. Maintain proper position of operated extremity.
Rationale: Reduces muscle spasm and undue tension on new prosthesis and surrounding tissues.
3. Provide comfort measures—frequent repositioning, back rub—and diversional activities. Encourage stress management techniques, such as progressive relaxation, guided imagery, visualization, and meditation. Provide Therapeutic Touch, as appropriate.
Rationale: Reduces muscle tension, refocuses attention, promotes sense of control, and may enhance coping abilities in the management of discomfort or pain, which can persist for an extended period.
4. Medicate on a regular schedule and before activities or procedures.
Rationale: Reduces muscle tension, improves comfort, and facilitates participation.
5. Investigate reports of sudden, severe joint pain with muscle spasms and changes in joint mobility, or sudden, severe chest pain with dyspnea and restlessness.
Rationale: Early recognition of developing problems, such as dislocation of prosthesis or blood or fat pulmonary emboli, provides opportunity for prompt intervention and prevention of more serious complications.
6. Administer medications as indicated, around the clock, such as: Opioids—instruct in and monitor use of patient-controlled analgesia (PCA), epidural administration, and/or pain ball
Rationale: Relieves surgical pain and reduces muscle tension and spasm, which contribute to overall discomfort. Opioid infusion (including epidural) may be given during the first 24 to 48 hours. The ON-Q PainBuster® ball provides continuous infusion of local anesthetic directly into surgical site for up to 5 days, thus decreasing need for opioids, and allows for earlier ambulation than epidural administration.
7. Analgesics, such as, oxycodone (Percocet), hycodone and acetaminophen (Vicodin), and muscle relaxants
Rationale: Oral analgesics are added to pain management program as the client progresses. Note: Use of ketorolac (Toradol) or other nonsteroidal anti-inflammatory drug (NSAID) is contraindicated when client is receiving enoxaparin (Lovenox) therapy.
8. Apply ice packs, as indicated.
Rationale: Promotes vasoconstriction to reduce bleeding and tissue edema in surgical area and lessens perception of discomfort.
9. Initiate and maintain extremity mobilization, such as, ambulation, physical therapy, exerciser, or continuous passive motion (CPM) device.
Rationale: Increases circulation to affected muscles. Minimizes joint stiffness; relieves muscle spasms related to disuse.
Thursday, March 17, 2011
Acute Pain | Nursing Care Plan for Cholecystitis
Nursing diagnosis: acute Pain related to Biological injuring agents: obstruction or ductal spasm, inflammatory process, tissue ischemia and necrosis.
Possibly evidenced by
Reports of pain, biliary colic
Facial mask of pain; guarding behavior
Autonomic responses including changes in blood pressure (BP), pulse
Self-focusing; narrowed focus
Desired Outcomes/Evaluation Criteria—Client Will
Pain Control
Report pain is relieved or controlled.
Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.
Nursing intervention with rationale:
1. Observe and document location, severity (0 to 10 scale), and character of pain, such as steady, intermittent, or colicky.
Rationale: Assists in differentiating cause of pain and provides information about disease progression or resolution, development of complications, and effectiveness of interventions.
2. Note response to medication, and report to physician if pain is not being relieved.
Rationale: Severe pain not relieved by routine measures may indicate developing complications and the need for further intervention.
3. Promote bedrest, allowing client to assume position of comfort.
Rationale: Bedrest in low-Fowler’s position reduces intra-abdominal pressure; however, client will naturally assume least painful position.
4. Use soft cotton linens; calamine lotion; oil bath; and cool, moist compresses, as indicated.
Rationale: Reduces irritation and dryness of the skin and itching sensation.
5. Control environmental temperature.
Rationale: Cool surroundings aid in minimizing dermal discomfort.
6. Encourage use of relaxation techniques such as guided imagery, visualization, and deep-breathing exercises. Provide diversional activities.
Rationale: Promotes rest, redirects attention, and may enhance coping.
7. Make time to listen to and maintain frequent contact with client.
Rationale: Helpful in alleviating anxiety and refocusing attention, which can relieve pain.
8. Maintain nothing by mouth (NPO) status; insert and maintain nasogastric (NG) suction, as indicated.
Rationale: Removes gastric secretions that stimulate release of cholecystokinin and gallbladder contractions.
9. Prepare for procedures, such as the following: Endoscopic sphincterotomy plus extraction of stones during ERCP
Rationale: Procedure done to widen the mouth of the common bile duct where it empties into the duodenum. The procedure may be done to assist in retrieving stones from the common duct by means of a tiny basket or balloon on the end of the endoscope. Stones must be smaller than 15 mm. Larger stones may be crushed with a mechanical lithotripter inserted through the endoscope.
10. Extracorporeal shock wave lithotripsy (ESWL)
Rationale: Shock wave treatment is a little-used therapy due to high recurrence of stones. It may be indicated in a client with mild to moderate symptoms, with a single cholesterol stone (0.5 mm or larger), or in client without biliary tract obstruction. Note: This procedure is contraindicated in clients with pacemakers or implantable defibrillators.
Possibly evidenced by
Reports of pain, biliary colic
Facial mask of pain; guarding behavior
Autonomic responses including changes in blood pressure (BP), pulse
Self-focusing; narrowed focus
Desired Outcomes/Evaluation Criteria—Client Will
Pain Control
Report pain is relieved or controlled.
Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.
Nursing intervention with rationale:
1. Observe and document location, severity (0 to 10 scale), and character of pain, such as steady, intermittent, or colicky.
Rationale: Assists in differentiating cause of pain and provides information about disease progression or resolution, development of complications, and effectiveness of interventions.
2. Note response to medication, and report to physician if pain is not being relieved.
Rationale: Severe pain not relieved by routine measures may indicate developing complications and the need for further intervention.
3. Promote bedrest, allowing client to assume position of comfort.
Rationale: Bedrest in low-Fowler’s position reduces intra-abdominal pressure; however, client will naturally assume least painful position.
4. Use soft cotton linens; calamine lotion; oil bath; and cool, moist compresses, as indicated.
Rationale: Reduces irritation and dryness of the skin and itching sensation.
5. Control environmental temperature.
Rationale: Cool surroundings aid in minimizing dermal discomfort.
6. Encourage use of relaxation techniques such as guided imagery, visualization, and deep-breathing exercises. Provide diversional activities.
Rationale: Promotes rest, redirects attention, and may enhance coping.
7. Make time to listen to and maintain frequent contact with client.
Rationale: Helpful in alleviating anxiety and refocusing attention, which can relieve pain.
8. Maintain nothing by mouth (NPO) status; insert and maintain nasogastric (NG) suction, as indicated.
Rationale: Removes gastric secretions that stimulate release of cholecystokinin and gallbladder contractions.
9. Prepare for procedures, such as the following: Endoscopic sphincterotomy plus extraction of stones during ERCP
Rationale: Procedure done to widen the mouth of the common bile duct where it empties into the duodenum. The procedure may be done to assist in retrieving stones from the common duct by means of a tiny basket or balloon on the end of the endoscope. Stones must be smaller than 15 mm. Larger stones may be crushed with a mechanical lithotripter inserted through the endoscope.
10. Extracorporeal shock wave lithotripsy (ESWL)
Rationale: Shock wave treatment is a little-used therapy due to high recurrence of stones. It may be indicated in a client with mild to moderate symptoms, with a single cholesterol stone (0.5 mm or larger), or in client without biliary tract obstruction. Note: This procedure is contraindicated in clients with pacemakers or implantable defibrillators.
Monday, March 14, 2011
Acute Pain | Nursing Care Plan for Peritonitis
Nursing diagnosis: acute Pain related to Chemical irritation of the parietal peritoneum (toxins), Trauma to tissues, Accumulation of fluid in abdominal and peritoneal cavity (abdominal distention)
Possibly evidenced by
Verbalizations of pain
Muscle guarding, rebound tenderness
Facial mask of pain, self-focus
Distraction behavior, autonomic or emotional responses (anxiety)
Desired Outcomes/Evaluation Criteria—Client Will
Pain Control
Report pain is relieved or controlled.
Demonstrate use of relaxation skills or other methods to promote comfort.
Nursing intervention with rationale:
1. Investigate pain reports, noting location, duration, intensity (0 to 10 scale), and characteristics such as dull, sharp, or constant.
Rationale: Changes in location or intensity are not uncommon but may reflect developing complications. Pain tends to become constant, more intense, and diffuse over the entire abdomen as inflammatory process accelerates; pain may localize if an abscess develops.
2. Maintain semi-Fowler’s position as indicated.
Rationale: Facilitates fluid and wound drainage by gravity, reducing diaphragmatic irritation and abdominal tension, thereby reducing pain.
3. Move client slowly and deliberately, splinting painful area.
Rationale: Reduces muscle tension and guarding, which may help minimize pain of movement.
4. Provide comfort measures, such as massage, back rubs, and deep breathing. Instruct in relaxation and visualization exercises. Provide diversional activities.
Rationale: Promotes relaxation and may enhance client’s coping abilities by refocusing attention.
5. Provide frequent oral care. Remove noxious environmental stimuli.
Rationale: Reduces nausea and vomiting, which can increase intra-abdominal pressure and pain.
6. Administer medications, as indicated, for example: Analgesics and opioids
Rationale: Reduces metabolic rate and intestinal irritation from circulating and local toxins, which aid in pain relief and promote healing. Note: Pain is usually severe and may require opioid pain control.
7. Antiemetics, such as hydroxyzine (Vistaril)
Rationale: Reduces the nausea and vomiting that can increase abdominal pain.
8. Antipyretics, such as acetaminophen (Tylenol)
Rationale: Reduces discomfort associated with fever.
Possibly evidenced by
Verbalizations of pain
Muscle guarding, rebound tenderness
Facial mask of pain, self-focus
Distraction behavior, autonomic or emotional responses (anxiety)
Desired Outcomes/Evaluation Criteria—Client Will
Pain Control
Report pain is relieved or controlled.
Demonstrate use of relaxation skills or other methods to promote comfort.
Nursing intervention with rationale:
1. Investigate pain reports, noting location, duration, intensity (0 to 10 scale), and characteristics such as dull, sharp, or constant.
Rationale: Changes in location or intensity are not uncommon but may reflect developing complications. Pain tends to become constant, more intense, and diffuse over the entire abdomen as inflammatory process accelerates; pain may localize if an abscess develops.
2. Maintain semi-Fowler’s position as indicated.
Rationale: Facilitates fluid and wound drainage by gravity, reducing diaphragmatic irritation and abdominal tension, thereby reducing pain.
3. Move client slowly and deliberately, splinting painful area.
Rationale: Reduces muscle tension and guarding, which may help minimize pain of movement.
4. Provide comfort measures, such as massage, back rubs, and deep breathing. Instruct in relaxation and visualization exercises. Provide diversional activities.
Rationale: Promotes relaxation and may enhance client’s coping abilities by refocusing attention.
5. Provide frequent oral care. Remove noxious environmental stimuli.
Rationale: Reduces nausea and vomiting, which can increase intra-abdominal pressure and pain.
6. Administer medications, as indicated, for example: Analgesics and opioids
Rationale: Reduces metabolic rate and intestinal irritation from circulating and local toxins, which aid in pain relief and promote healing. Note: Pain is usually severe and may require opioid pain control.
7. Antiemetics, such as hydroxyzine (Vistaril)
Rationale: Reduces the nausea and vomiting that can increase abdominal pain.
8. Antipyretics, such as acetaminophen (Tylenol)
Rationale: Reduces discomfort associated with fever.
Friday, March 11, 2011
Acute Pain | Nursing Diagnosis for Appendectomy
Nursing diagnosis: acute Pain related to Distention of intestinal tissues by inflammation, Presence of surgical incision
Possibly evidenced by
Reports of pain
Facial grimacing, muscle guarding, distraction behaviors
Autonomic responses
Desired Outcomes/Evaluation Criteria—Client Will
Pain Level
Report pain is relieved or controlled.
Appear relaxed, able to sleep and rest appropriately.
Nursing intervention with rationale:
1. Assess pain, noting location, characteristics, and severity (0 to 10 scale). Investigate and report changes in pain, as appropriate.
Rationale: Useful in monitoring effectiveness of medication and progression of healing. Changes in characteristics of pain may indicate developing abscess or peritonitis, requiring prompt medical evaluation and intervention.
2. Provide accurate, honest information to client/ significant other (SO).
Rationale: Being informed about progress of situation provides emotional support, helping to decrease anxiety.
3. Keep at rest in semi-Fowler’s position.
Rationale: Gravity localizes inflammatory exudate into lower abdomen or pelvis, relieving abdominal tension, which is accentuated by supine position.
4. Encourage early ambulation.
Rationale: Promotes normalization of organ function; stimulates peristalsis and passing of flatus, reducing abdominal discomfort.
5. Provide diversional activities.
Rationale: Refocuses attention, promotes relaxation, and may enhance coping abilities.
6. Keep NPO and maintain NG suction initially.
Rationale: Decreases discomfort of early intestinal peristalsis and gastric irritation or vomiting.
7. Administer analgesics, as indicated.
Rationale: Relief of pain facilitates cooperation with other therapeutic interventions, such as ambulation and pulmonary toilet.
8. Place ice bag on abdomen periodically during initial 24 to 48 hours, as appropriate.
Rationale: Soothes and relieves pain through desensitization of nerve endings. Note: Do not use heat because it may cause tissue congestion and increase edema formation.
Possibly evidenced by
Reports of pain
Facial grimacing, muscle guarding, distraction behaviors
Autonomic responses
Desired Outcomes/Evaluation Criteria—Client Will
Pain Level
Report pain is relieved or controlled.
Appear relaxed, able to sleep and rest appropriately.
Nursing intervention with rationale:
1. Assess pain, noting location, characteristics, and severity (0 to 10 scale). Investigate and report changes in pain, as appropriate.
Rationale: Useful in monitoring effectiveness of medication and progression of healing. Changes in characteristics of pain may indicate developing abscess or peritonitis, requiring prompt medical evaluation and intervention.
2. Provide accurate, honest information to client/ significant other (SO).
Rationale: Being informed about progress of situation provides emotional support, helping to decrease anxiety.
3. Keep at rest in semi-Fowler’s position.
Rationale: Gravity localizes inflammatory exudate into lower abdomen or pelvis, relieving abdominal tension, which is accentuated by supine position.
4. Encourage early ambulation.
Rationale: Promotes normalization of organ function; stimulates peristalsis and passing of flatus, reducing abdominal discomfort.
5. Provide diversional activities.
Rationale: Refocuses attention, promotes relaxation, and may enhance coping abilities.
6. Keep NPO and maintain NG suction initially.
Rationale: Decreases discomfort of early intestinal peristalsis and gastric irritation or vomiting.
7. Administer analgesics, as indicated.
Rationale: Relief of pain facilitates cooperation with other therapeutic interventions, such as ambulation and pulmonary toilet.
8. Place ice bag on abdomen periodically during initial 24 to 48 hours, as appropriate.
Rationale: Soothes and relieves pain through desensitization of nerve endings. Note: Do not use heat because it may cause tissue congestion and increase edema formation.
Monday, March 7, 2011
Acute Pain | Nursing Care Plan for Fecal Diversions
Nursing diagnosis: acute pain related to Physical factors—disruption of skin or tissues (incisions, drains), Biological factors—activity of disease process (cancer, trauma), Psychological factors—fear, anxiety
Possibly evidenced by
Reports of pain, self-focusing
Guarding and distraction behaviors, restlessness
Autonomic responses—changes in vital signs
Desired Outcomes/Evaluation Criteria—Client Will
Pain Level
Verbalize that pain is relieved or controlled.
Appear relaxed and able to sleep or rest appropriately.
Pain Control
Demonstrate use of relaxation skills and general comfort measures, as indicated for individual situation.
Nursing intervention with rationale:
1. Assess pain, noting location, characteristics, and intensity (such as 0–10 scale).
Rationale: Helps evaluate degree of discomfort and effectiveness of analgesia or may reveal developing complications. Because abdominal pain usually subsides gradually by the third or fourth postoperative day, continued or increasing pain may reflect delayed healing or peristomal skin irritation. Note: Pain in anal area associated with abdominal-perineal resection may persist for months.
2. Encourage client to verbalize concerns. Active-listen these concerns, and provide support by acceptance, remaining with client, and giving appropriate information.
Rationale: Reduction of anxiety and fear can promote relaxation and comfort.
3. Provide comfort measures, such as mouth care, back rub, and repositioning. Assure client that position change will not injure stoma.
Rationale: Prevents drying of oral mucosa and associated discomfort. Reduces muscle tension, promotes relaxation, and may enhance coping abilities.
4. Encourage use of relaxation techniques such as guided imagery and visualization. Provide diversional activities.
Rationale: Helps client rest more effectively and refocuses attention, thereby reducing pain and discomfort.
5. Assist with range-of-motion exercises and encourage early ambulation. Avoid prolonged sitting position.
Rationale: Reduces muscle and joint stiffness. Ambulation returns organs to normal position and promotes return of usual level of functioning. Note: Presence of edema, packing, and drains (if perineal resection has been done) increases discomfort and creates a sense of needing to defecate. Ambulation and frequent position changes reduce perineal pressure.
6. Investigate and report abdominal muscle rigidity, involuntary guarding, and rebound tenderness.
Rationale: Suggestive of peritoneal inflammation, which requires prompt medical intervention.
7. Administer medication, such as opioids, analgesics, and patient-controlled analgesia (PCA), as indicated.
Rationale: Relieves pain, enhances comfort, and promotes rest. PCA may be more beneficial, especially following anal-perineal repair.
8. Provide sitz baths.
Rationale: Relieves local discomfort, reduces edema, and promotes healing of perineal wound.
9. Apply and monitor effects of transcutaneous electrical nerve stimulator unit.
Rationale: Cutaneous stimulation may be used to block transmission of pain stimulus.
Possibly evidenced by
Reports of pain, self-focusing
Guarding and distraction behaviors, restlessness
Autonomic responses—changes in vital signs
Desired Outcomes/Evaluation Criteria—Client Will
Pain Level
Verbalize that pain is relieved or controlled.
Appear relaxed and able to sleep or rest appropriately.
Pain Control
Demonstrate use of relaxation skills and general comfort measures, as indicated for individual situation.
Nursing intervention with rationale:
1. Assess pain, noting location, characteristics, and intensity (such as 0–10 scale).
Rationale: Helps evaluate degree of discomfort and effectiveness of analgesia or may reveal developing complications. Because abdominal pain usually subsides gradually by the third or fourth postoperative day, continued or increasing pain may reflect delayed healing or peristomal skin irritation. Note: Pain in anal area associated with abdominal-perineal resection may persist for months.
2. Encourage client to verbalize concerns. Active-listen these concerns, and provide support by acceptance, remaining with client, and giving appropriate information.
Rationale: Reduction of anxiety and fear can promote relaxation and comfort.
3. Provide comfort measures, such as mouth care, back rub, and repositioning. Assure client that position change will not injure stoma.
Rationale: Prevents drying of oral mucosa and associated discomfort. Reduces muscle tension, promotes relaxation, and may enhance coping abilities.
4. Encourage use of relaxation techniques such as guided imagery and visualization. Provide diversional activities.
Rationale: Helps client rest more effectively and refocuses attention, thereby reducing pain and discomfort.
5. Assist with range-of-motion exercises and encourage early ambulation. Avoid prolonged sitting position.
Rationale: Reduces muscle and joint stiffness. Ambulation returns organs to normal position and promotes return of usual level of functioning. Note: Presence of edema, packing, and drains (if perineal resection has been done) increases discomfort and creates a sense of needing to defecate. Ambulation and frequent position changes reduce perineal pressure.
6. Investigate and report abdominal muscle rigidity, involuntary guarding, and rebound tenderness.
Rationale: Suggestive of peritoneal inflammation, which requires prompt medical intervention.
7. Administer medication, such as opioids, analgesics, and patient-controlled analgesia (PCA), as indicated.
Rationale: Relieves pain, enhances comfort, and promotes rest. PCA may be more beneficial, especially following anal-perineal repair.
8. Provide sitz baths.
Rationale: Relieves local discomfort, reduces edema, and promotes healing of perineal wound.
9. Apply and monitor effects of transcutaneous electrical nerve stimulator unit.
Rationale: Cutaneous stimulation may be used to block transmission of pain stimulus.
Monday, February 28, 2011
Acute Pain | Nursing Care Plan (NCP) for Inflammatory Bowel Disease
Nursing diagnosis: acute Pain related to Hyperperistalsis, prolonged diarrhea, skin and tissue irritation, perirectal excoriation, fissures, fistulas
Possibly evidenced by
Reports of colicky, cramping abdominal pain; referred pain
Guarding or distraction behaviors, restlessness
Facial mask of pain; self-focusing
Desired Outcomes/Evaluation Criteria—Client Will
Pain Level
Report pain is relieved or controlled.
Appear relaxed and able to sleep and rest appropriately.
Nursing intervention with rationale:
1. Encourage client to report pain.
Rationale: May try to tolerate pain rather than request analgesics.
2. Assess reports of abdominal cramping or pain, noting location, duration, and intensity (such as 0–10 scale). Investigate and report changes in pain characteristics.
Rationale: Colicky intermittent pain occurs with Crohn’s disease. Predefecation pain frequently occurs in UC with urgency, which may be severe and continuous. Changes in pain characteristics may indicate spread of disease or developing complications, such as bladder fistula, perforation, and toxic megacolon.
3. Note nonverbal cues, such as restlessness, reluctance to move, abdominal guarding, withdrawal, and depression. Investigate discrepancies between verbal and nonverbal cues.
Rationale: Body language or nonverbal cues may be both physiological and psychological and may be used in conjunction with verbal cues to determine extent and severity of the problem.
4. Review factors that aggravate or alleviate pain.
Rationale: May pinpoint precipitating or aggravating factors (e.g., stressful events, food intolerance) or identify developing complications.
5. Encourage client to assume position of comfort, such as knees flexed.
Rationale: Reduces abdominal tension and promotes sense of control.
6. Provide comfort measures (e.g., back rub, reposition) and diversional activities.
Rationale: Promotes relaxation, refocuses attention, and may enhance coping abilities.
7. Cleanse rectal area with mild soap and water (or wipes) after each stool and provide skin care with a moisture barrier ointment (e.g., A&D ointment, Sween ointment, karaya gel, Desitin, petroleum jelly, zinc oxide, dimethicone).
Rationale: Protects skin from bowel acids, preventing excoriation.
8. Implement prescribed dietary modifications, for example, commence with liquids and increase to solid foods as tolerated.
Rationale: Complete bowel rest can reduce pain and cramping.
9. Provide sitz bath, as appropriate.
Rationale: Enhances cleanliness and comfort in the presence of perianal irritation and fissures.
10. Observe and record abdominal distension, increased temperature, and decreased BP.
Rationale: May indicate developing intestinal obstruction from inflammation, edema, and scarring.
Sunday, February 6, 2011
5 Painful Facts You Need to Know
5 Painful Facts You Need to Know
By Robert Roy Britt (LiveScience, July 25, 2008) 
alphachimp.com
First off, let's set the record straight: Pain is normal. About 75 million U.S. residents endure chronic or recurrent pain. Migraines plague 25 million of us. One in six suffer arthritis.
The global pain industry peddles more than $50 billion in drugs a year. Yet for chronic pain sufferers, over-the-counter pills are typically little help, while morphine and other narcotics can be addictive sedatives.
An overview study published last month in the Journal of General Internal Medicine looked at multiple studies of pain and found "researchers don't yet know how to determine which [treatment] is best for individual patients." From studies of drugs to surgeries and alternative medicines, "We have found that there are huge gaps in our knowledge base," said Dr. Matthew J. Bair, assistant professor of medicine at the Indiana University School of Medicine.
So what is pain and why do so many suffer so long?
Pain is felt when electrical signals are sent from nerve endings to your brain, which in turn can release painkillers called endorphins and generate reactions that range from instant and physical to long-term and emotional. Beyond that, scientific understanding gets painfully fuzzy. Here's what's known:
1. Scientist don't understand pain
When you're in pain, you know it. But if scientists could fully grasp how pain works and why, they might be able to help you more. The American Academy of Pain Medicine defines pain as "an unpleasant sensation and emotional response to that sensation." Some pain is the result of an obvious injury. Other times, it is caused by damaged nerves that are not so easy to pinpoint. "Pain is complex and defies our ability to establish a clear definition," says Kathryn Weiner, director of the American Academy of Pain Management. "Pain is far more than neural transmission and sensory transduction. Pain is a complex mixture of emotions, culture, experience, spirit and sensation."
2. Chronic pain shrinks brains
If you have chronic pain, you know how demoralizing and debilitating it can be, physically and mentally. It can prevent you from doing things and make you irritable for reasons nobody else understands. But that's only half the story. People with chronic backaches have brains as much as 11 percent smaller than those of non-sufferers, scientists reported in 2004. They don't know why. "It is possible it's just the stress of having to live with the condition," said study leader A. Vania Apkarian of Northwestern University. "The neurons become overactive or tired of the activity."
3. Migraines and sex go together
It may not eliminate the phrase "Not tonight, honey ..." but a 2006 study found that migraine sufferers had levels of sexual desire 20 percent higher than those suffering from tension headaches. The finding suggests sexual desire and migraines might be influenced by the same brain chemical, and getting a better handle on the link could lead to better treatments, at least for the pain portion of the equation.
4. Women feel more pain
Any man who has watched a woman having a baby without using drugs would swear that women can tolerate anything. But the truth is, guys, it hurts more than you can imagine. Women have more nerve receptors than men. As an example, women have 34 nerve fibers per square centimeter of facial skin, while men average just 17. And in a 2005 study, women were found to report more pain throughout their lifetimes and, compared to men, they feel pain in more areas of their body and for longer durations.
5. Some animals don't feel our pain
Animal research could offer clues to eventually relieve human suffering. Take the naked mole rat, a hairless and nearly blind subterranean creature. A study this year found it feels neither the pain of acid nor the sting of chili peppers. If researchers can figure out why, they might be on the road to new sorts of painkilling therapies for humans. In 2006, scientists found a pathway for the transmission of chronic pain in rats that they hope will translate into better understanding of human chronic pain. Lobsters feel no pain, even when boiled, scientists said in a 2005 report that is just one more salvo in a long-running debate.
Source : http://wisdomquarterly.blogspot.com
Nursing Diagnosis for Acute Pain - NANDA
Definition Nursing Diagnosis for Acute Pain:
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
Subjective data: from patient usually Verbal report of pain
Objective data: Observed evidence of pain, protective gestures avoid pain, Change in muscle tone, Expressive; restlessness, moaning, crying, vigilance, irritability, sighing
Nursing Outcomes Client Will:
- Report pain is relieved / controlled.
- Follow prescribed pharmacological regimen.
- Verbalize methods that provide relief.
- Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.
Nursing Priority Nursing Diagnosis for Acute Pain:
- To Assess Etiology/Precipitating Contributory Factors
- Evaluate Client’s Response To Pain
- Assist Client To Explore Methods For Alleviation/Control Of Pain
Sample Clinical Applications using Nursing Diagnosis for Acute Pain:
- Traumatic Injuries
- Surgical Procedures
- Infections
- Cancer
- Burns
- Skin Lesions
- Gangrene
- Thrombophlebitis
- Pulmonary Embolus
- Neuralgia
Saturday, February 5, 2011
Acute Pain | Nursing Care Plan for Spinal Cord Injury
Nursing diagnosis: acute Pain related to Physical injury; damage or dysfunction of nervous system, Traction apparatus
Possibly evidenced by
Verbal reports of pain; hyperalgesia immediately above level of injury, burning pain below level of injury (central pain), phantom pain, headaches
Muscle spasm, spasticity
Irritability; restlessness
Self-focusing
Sympathetic mediated responses—temperature, cold, changes of body position, hypersensitivity
Desired Outcomes/Evaluation Criteria—Client Will
Pain Control
Identify ways to manage pain.
Demonstrate use of relaxation skills and diversional activities as individually indicated.
Report relief or control of pain and discomfort.
Nursing intervention with rationale:
1. Assess for presence of pain. Help client identify and quantify pain, including, location, type of pain, and intensity on a scale of 0 to 10.
Rationale: Pain is a frequent problem in the majority of the SCI population and can occur not only above the level of injury but also at or below the level of injury and in both complete
and incomplete injuries. An individual with SCI is likely to experience many types of painful sensations at or below the level of injury that can be troublesome to categorize, making effective treatment difficult. Pain can be neuropathic (resulting from abnormal processing of sensory input); can be due to musculoskeletal disorders caused from injury at the time of SCI; or be associated with organ complications such as ulcers or constipation. Pain can also be “segmental,” felt at the level of injury in a bandlike pattern (Turner et al, 2001). Client often reports pain above the level of injury, such as chest, back, or headache, possibly from stabilizer apparatus. After resolution of spinal shock phase, client may also report muscle spasms and radicular pain, described as a burning or stabbing pain radiating in a dermatomal pattern—associated with injury to peripheral nerves. Onset of this pain is within days to weeks after SCI and may become chronic.
2. Evaluate increased irritability, muscle tension, restlessness, and unexplained vital sign changes.
Rationale: Nonverbal cues indicative of pain or discomfort require timely intervention.
3. Assist client in identifying precipitating factors.
Rationale: Burning pain and muscle spasms can be precipitated or aggravated by multiple factors, such as anxiety, tension, external temperature extremes, sitting for long periods, and bladder distention.
4. Provide comfort measures, such as position changes, massage, ROM exercises, and warm or cold packs, as indicated.
Rationale: Alternative measures for pain control reduce need for pharmacological agents and provide emotional support.
5. Encourage use of relaxation techniques, such as guided imagery, visualization, and deep-breathing exercises. Provide diversional activities—television, radio, telephone, and unlimited visitors, as appropriate.
Rationale: Relaxation and diversional activities refocus attention, promote sense of control, and possibly enhance coping abilities.
6. Administer medications, as indicated, for example: muscle relaxants, such as dantrolene (Dantrium) and baclofen (Lioresal); analgesics; anti-anxiety agents, such as, alprazalam (Xanax), and diazepam (Valium).
Rationale: These medications relieve muscle spasm and pain associated with spasticity. They also alleviate anxiety and promote rest.
Possibly evidenced by
Verbal reports of pain; hyperalgesia immediately above level of injury, burning pain below level of injury (central pain), phantom pain, headaches
Muscle spasm, spasticity
Irritability; restlessness
Self-focusing
Sympathetic mediated responses—temperature, cold, changes of body position, hypersensitivity
Desired Outcomes/Evaluation Criteria—Client Will
Pain Control
Identify ways to manage pain.
Demonstrate use of relaxation skills and diversional activities as individually indicated.
Report relief or control of pain and discomfort.
Nursing intervention with rationale:
1. Assess for presence of pain. Help client identify and quantify pain, including, location, type of pain, and intensity on a scale of 0 to 10.
Rationale: Pain is a frequent problem in the majority of the SCI population and can occur not only above the level of injury but also at or below the level of injury and in both complete
and incomplete injuries. An individual with SCI is likely to experience many types of painful sensations at or below the level of injury that can be troublesome to categorize, making effective treatment difficult. Pain can be neuropathic (resulting from abnormal processing of sensory input); can be due to musculoskeletal disorders caused from injury at the time of SCI; or be associated with organ complications such as ulcers or constipation. Pain can also be “segmental,” felt at the level of injury in a bandlike pattern (Turner et al, 2001). Client often reports pain above the level of injury, such as chest, back, or headache, possibly from stabilizer apparatus. After resolution of spinal shock phase, client may also report muscle spasms and radicular pain, described as a burning or stabbing pain radiating in a dermatomal pattern—associated with injury to peripheral nerves. Onset of this pain is within days to weeks after SCI and may become chronic.
2. Evaluate increased irritability, muscle tension, restlessness, and unexplained vital sign changes.
Rationale: Nonverbal cues indicative of pain or discomfort require timely intervention.
3. Assist client in identifying precipitating factors.
Rationale: Burning pain and muscle spasms can be precipitated or aggravated by multiple factors, such as anxiety, tension, external temperature extremes, sitting for long periods, and bladder distention.
4. Provide comfort measures, such as position changes, massage, ROM exercises, and warm or cold packs, as indicated.
Rationale: Alternative measures for pain control reduce need for pharmacological agents and provide emotional support.
5. Encourage use of relaxation techniques, such as guided imagery, visualization, and deep-breathing exercises. Provide diversional activities—television, radio, telephone, and unlimited visitors, as appropriate.
Rationale: Relaxation and diversional activities refocus attention, promote sense of control, and possibly enhance coping abilities.
6. Administer medications, as indicated, for example: muscle relaxants, such as dantrolene (Dantrium) and baclofen (Lioresal); analgesics; anti-anxiety agents, such as, alprazalam (Xanax), and diazepam (Valium).
Rationale: These medications relieve muscle spasm and pain associated with spasticity. They also alleviate anxiety and promote rest.
Thursday, February 3, 2011
Chest Pain Treatment
Self-Care at Home
Heart Attack
If you suspect that you or someone you are with may be having a heart attack, call 911 for emergency services or go to the nearest hospital emergency department.
- While waiting for the ambulance, have the patient chew two baby aspirin or at least half of a regular aspirin - at least 160 mg. There is no evidence that taking more than this helps more, and the patient could have unwanted side effects if they take too much.
- It is important to chew the aspirin before swallowing it because chewing decreases the time the medicine takes to have an effect.
- Chewing an aspirin in the early stages of a heart attack may reduce the risk of death and it may also reduce the severity of the attack.
Angina
If the patient has had angina and has nitroglycerin tablets available, have the patient place one under the tongue. This may aid in increasing blood flow to blocked or narrowed arteries.
- If the chest pain continues in the next five minutes, take another tablet under the tongue.
- If, after three nitroglycerin tablets, the patient does not have relief of the chest pain, immediately call 911 or go to the nearest emergency department.
Esophagus
If the pain is from acid reflux (GERD), it may be relieved with antacids. Even if the patient's pain goes away after taking an antacid, do not assume they are not having a heart attack. The patient should still be evaluated in a hospital emergency department.
Source : www.emedicinehealth.com
Top Tips to Treat Chest Pain
Top Tips to Treat Chest Pain
Author: Raymond Lee
Chest pain is a serious symptom meaning “heart attack” to most people. Serious chest discomfort should usually be evaluated by a physician right now. On the way to the emergency room or while waiting for the ambulance, take two aspirin tablets. While pain from the heart may sometimes be mild, it is usually intense. Sometimes a feeling of pressure or squeezing on the chest is more prominent than actual pain. Almost always the pain or discomfort will be felt in part below the breastbone. It may also be felt in the jaw or down the inner part of either arm. There may be nausea and sweating. If dizziness, shortness of breath, or irregularity of the pulse is present, it is particularly important that a physician be seen immediately.
A related form of heart pain is not a heart attack but is termed “angina pectoris” or “angina.” These pains also can occur in the upper arms or the jaw, but usually involve part of the breastbone. Angina pains occur with exercise and sometimes with stress, and they go away with rest and relaxation. They are a result of narrowed arteries to the heart that are unable to supply enough blood when the heart is working hard. In a heart attack, one of these same arteries has actually become totally blocked. However, all chest pain does not come from the heart. Pain can also come from the chest wall, the lungs, the outside covering of the lungs, the outside covering of the heart, the esophagus, the diaphragm, the spine, the skin, or the organs in the upper part of the abdominal cavity. Often it is difficult even for a physician to determine the precise origin of the pain. Therefore there are no absolute rules that enable you to determine which pains may be treated at home. The following guidelines usually work and are used by doctors, but there are occasional exceptions.
A shooting pain lasting a few seconds is common and means nothing. A sensation of a “catch” at the end of a deep breath is also trivial and does not need attention. Chest wall pain can be demonstrated by pressing a finger on the chest at the spot of discomfort and reproducing or aggravating the pain by this maneuver. Pleurisy gets worse with a deep breath, heart pain does not. When pericarditis is present, the pain may throb with each heartbeat. Ulcer pain burns with an empty stomach and gets better with food, gallbladder pain often becomes more intense after a meal. Each of these four conditions, when suspected, should be evaluated by a physician.
Spasm of the esophagus can cause severe pain mimicking a heart attack and is quite different from the acid-burning that we called heartburn. This spasm pain feels as if it is expanding from inside the chest rather than squeezing from the outside as does heart pain. And it is often relieved by a drink of water, while heart pain is not.
If your chest pain is a new sensation and you are not sure what is going on, you should be evaluated promptly in an emergency medical facility. This is a complaint for which it is better to be conservative. See a doctor. Exceptions are chest wall pain, particularly if you had unusual exertion a day or so before, or pain that you are sure is coming from the esophagus. These you can treat with rest and acetaminophen, in the case of chest wall pain, and water and antacids, in the case of pain coming from the esophagus.
Article Source: http://www.articlesbase.com/diseases-and-conditions-articles/top-tips-to-treat-chest-pain-262167.html
About the Author
Raymond Lee is one of the foremost experts in the health and fitness industry and is the Founder of Bodyfixes Group specializing in body health, muscle development and dieting. He is currently the author of the latest edition of "Neck Exercises and Workouts." Visit http://www.bodyfixes.com for more information.
Chest Pain Prevention
Chest Pain Prevention :
Make healthy lifestyle choices to prevent chest pain from heart disease :
- Achieve and maintain normal weight.
- Control high blood pressure, high cholesterol, and diabetes.
- Avoid cigarette smoking and secondhand smoke.
- Eat a diet low in saturated and hydrogenated fats and cholesterol, and high in starches, fiber, fruits, and vegetables.
- Get at least 30 minutes of moderate intensity exercise on most days of the week.
- Reduce stress.
Wednesday, February 2, 2011
Anxiety Chest Pain: How To End It For Good
Anxiety Chest Pain: How To End It For Good
Author: Charlie Watson
Anxiety is nothing more than a malfunctioning of a totally ordinary bodily activity. It's not at all a disease or illness, but a behavioural condition which can be easily reversed using a world renowned method that has cured hundreds and thousands of sufferers world wide and it will cure you too.
The Linden Method
If you suffer anxiety chest pain and have not already heard of the 'Linden Method', then it makes me happy to be the one to introduce it to you, for it really is the key to getting rid of your anxiety disorder for good. This method was developed by Charles Linden, perhaps the world's top rated anxiety expert.
Anxiety Is A Habit
Anxiety disorder is a behavioural condition - it is not an illness or disease. It's not even a disorder. It is simply just a habit, controlled and stimulated by a little organ in the brain known as the 'amygdala'. Again, this is medical fact. Any professional on anxiety will confirm this.
Anxiety performs a vey crucial job in your body, when it's appropriate ie any time we are faced with genuine imminent danger, for example in the event that a wild animal were to chase after us. Anxiety disorder, however, is inappropriate anxiety. Anxiety evolves into a disorder purely because the body has effectively become accustomed to being anxious on a regular basis. While anxiety levels elevate, maybe on account of stress or living problems, the subconscious mind rewires itself to shift to this anxious behaviour. The amygdala is subsequently reset to this inappropriate anxiety benchmark for the reason that the brain believes that this anxious practice has become the new status quo.
This causes the individual to experience physical symptoms of anxiety for instance anxiety chest pain in scenarios when he or she might ordinarily feel pretty relaxed. Consciously this individual is aware that this is innapropriate, but the subconscious habit has taken store. Doesn't this just make so much sense? I hope it does, because again this is not some mad scientist idea, it is basic medical truth.
You Must Get Rid Of the Anxious Habit In Order To Cure Anxiety And Put A Stop To Anxiety Chest Pain
Now that you realize anxiety disorder is not an disease, but rather a habit, it ought to now make sense when I tell you that the sole option to break free of the anxiety pitfall you are in and to purge yourself of anxiety chest pain once and for all, is to learn new non-anxious behaviour.
Fact - this is the only cure for anxiety and anxiety related problems, Not because I am a smarty pants and that I say it is, but because to eliminate your anxiety you need to wipe out the subconscious habit. There is absolutely other way. Everybody that has ever recovered from anxiety disorder has done so applying the Linden Method in some mode or other - the difference is that those people who did this whilst being ignorant of the Linden Method obviously made it happen unintentionally, while people that implemented the Linden Method made a mindful determination to accomplish this.
Is The Linden Method Hard To Apply? How Lond Will It Take?
Honestly, no it's not at all hard. The method is straightforward to implement and it will work on every person, 100 % of the time (I must emphasise this!). On implementing the method your anxiety and symptoms will immediately subside and within a few weeks - times vary depending on the indiviual and the severity of his or her condition - completely disappear.
Article Source: http://www.articlesbase.com/wellness-articles/anxiety-chest-pain-how-to-end-it-for-good-3738496.html
About the Author
I am the owner of curedepressionanxiety.com a resource dedicated to helping anxiety and panic attacks sufferes discover the Linden Method, the world's premier natural anxiety cure
Thursday, January 27, 2011
Acute Pain | Nursing Care Plan for Disc Surgery
Nursing diagnosis: acute Pain related to physical agent: surgical manipulation, edema, inflammation, or harvesting of bone graft
Possibly evidenced by
Reports of pain
Autonomic responses: diaphoresis, changes in vital signs, pallor
Alteration in muscle tone
Guarding, distraction behaviors or restlessness
Desired Outcomes/Evaluation Criteria—Client Will
Pain Self-Control
Report pain is relieved or controlled.
Verbalize methods that provide relief.
Demonstrate use of relaxation skills and diversional activities.
Nursing intervention with rationale
1. Assess intensity, description, location, radiation of pain, and changes in sensation.
Rationale: Pain may be mild to severe with radiation to shoulders and occipital area (cervical) or hips and buttocks (lumbar). If bone graft has been taken from the iliac crest, pain may be more severe at the donor site. Numbness or tingling discomfort may reflect return of sensation after nerve root decompression or result from developing edema causing nerve compression.
2. Instruct in regular use of rating scale, such as 0 to 10.
Rationale: Standardized tool for rating pain helps in assessment and management of pain.
3. Review expected manifestations or changes in intensity of pain.
Rationale: Development or resolution of edema and inflammation during the immediate postoperative phase can affect pressure on various nerves and cause changes in degree of pain. Muscle spasms and improved nerve root sensation intensify pain, especially 3 days after procedure.
4. Encourage client to assume position of comfort, as indicated. Use logrolling for position change.
Rationale: Positioning is dictated by physical preference and type of operation; for example, head of bed may be slightly elevated after cervical laminectomy. Readjustment of position aids in relieving muscle fatigue and discomfort. Logrolling avoids tension in the operative areas, maintains straight spinal alignment, and reduces risk of displacing epidural patient-controlled analgesia (PCA) when used.
5. Provide back rub or massage. Avoid the operative site.
Rationale: Back rubs and massages relieve or reduce pain by alteration of sensory neurons and muscle relaxation.
6. Demonstrate and encourage use of relaxation skills, such as deep breathing, visualization, and so on.
Rationale: Deep breathing and visualization refocus attention, reduce muscle tension, promote sense of well-being, and control or decrease discomfort.
7. Provide liquid or soft diet; provide room humidifier; and encourage voice rest.
Rationale: Following anterior cervical laminectomy, such measures reduce discomfort associated with sore throat and difficulty swallowing.
8. Investigate client reports of return of radicular pain.
Rationale: Radicular pain suggests complications, such as collapsing of disc space and shifting of bone graft, which require further medical evaluation and intervention. Note: Sciatica and muscle spasms often recur after laminectomy, but should resolve within several days or weeks.
9. Administer analgesics, as indicated, for example: Opioids, such as morphine sulfate (MS), codeine, meperidine (Demerol), tramadol (Ultram), oxycodone (Percocet), and hydrocodone (Vicodin, Lortab)
Rationale: Opioids are used during the first few postoperative days. Nonopioid agents are incorporated as intensity of pain diminishes. Note: Opioids may be administered via epidural catheter and PCA.
10. Instruct client in use of PCA.
Rationale: PCA gives client control of medication administration (usually opioids) to achieve a more constant level of comfort, which may enhance healing and sense of well-being.
Possibly evidenced by
Reports of pain
Autonomic responses: diaphoresis, changes in vital signs, pallor
Alteration in muscle tone
Guarding, distraction behaviors or restlessness
Desired Outcomes/Evaluation Criteria—Client Will
Pain Self-Control
Report pain is relieved or controlled.
Verbalize methods that provide relief.
Demonstrate use of relaxation skills and diversional activities.
Nursing intervention with rationale
1. Assess intensity, description, location, radiation of pain, and changes in sensation.
Rationale: Pain may be mild to severe with radiation to shoulders and occipital area (cervical) or hips and buttocks (lumbar). If bone graft has been taken from the iliac crest, pain may be more severe at the donor site. Numbness or tingling discomfort may reflect return of sensation after nerve root decompression or result from developing edema causing nerve compression.
2. Instruct in regular use of rating scale, such as 0 to 10.
Rationale: Standardized tool for rating pain helps in assessment and management of pain.
3. Review expected manifestations or changes in intensity of pain.
Rationale: Development or resolution of edema and inflammation during the immediate postoperative phase can affect pressure on various nerves and cause changes in degree of pain. Muscle spasms and improved nerve root sensation intensify pain, especially 3 days after procedure.
4. Encourage client to assume position of comfort, as indicated. Use logrolling for position change.
Rationale: Positioning is dictated by physical preference and type of operation; for example, head of bed may be slightly elevated after cervical laminectomy. Readjustment of position aids in relieving muscle fatigue and discomfort. Logrolling avoids tension in the operative areas, maintains straight spinal alignment, and reduces risk of displacing epidural patient-controlled analgesia (PCA) when used.
5. Provide back rub or massage. Avoid the operative site.
Rationale: Back rubs and massages relieve or reduce pain by alteration of sensory neurons and muscle relaxation.
6. Demonstrate and encourage use of relaxation skills, such as deep breathing, visualization, and so on.
Rationale: Deep breathing and visualization refocus attention, reduce muscle tension, promote sense of well-being, and control or decrease discomfort.
7. Provide liquid or soft diet; provide room humidifier; and encourage voice rest.
Rationale: Following anterior cervical laminectomy, such measures reduce discomfort associated with sore throat and difficulty swallowing.
8. Investigate client reports of return of radicular pain.
Rationale: Radicular pain suggests complications, such as collapsing of disc space and shifting of bone graft, which require further medical evaluation and intervention. Note: Sciatica and muscle spasms often recur after laminectomy, but should resolve within several days or weeks.
9. Administer analgesics, as indicated, for example: Opioids, such as morphine sulfate (MS), codeine, meperidine (Demerol), tramadol (Ultram), oxycodone (Percocet), and hydrocodone (Vicodin, Lortab)
Rationale: Opioids are used during the first few postoperative days. Nonopioid agents are incorporated as intensity of pain diminishes. Note: Opioids may be administered via epidural catheter and PCA.
10. Instruct client in use of PCA.
Rationale: PCA gives client control of medication administration (usually opioids) to achieve a more constant level of comfort, which may enhance healing and sense of well-being.
Monday, November 29, 2010
Acute Pain | Nursing Care Plan for Lung Cancer
Nursing diagnosis: acute pain related to surgical incision, tissue trauma, and disruption of intercostal nerves; presence of chest tube(s); cancer invasion of pleura, chest wall
Possibly evidenced by
Verbal reports of discomfort
Guarding of affected area
Distraction behaviors such as restlessness
Narrowed focus, withdrawal
Changes in blood pressure (BP), heart, or respiratory rate
Desired Outcomes/Evaluation Criteria—Client Will
Pain Level
Report pain relieved or controlled.
Appear relaxed and sleep or rest appropriately.
Participate in desired as well as needed activities.
Nursing intervention with rationale:
1. Ask client about pain. Determine pain location and characteristics; for example, continuous, aching, stabbing, or burning. Have client rate intensity on a scale of 0 to 10.
Rationale: Helpful in evaluating cancer-related pain symptoms, which may involve viscera, nerve, or bone tissue. Use of rating scale aids client in assessing level of pain and provides tool
for evaluating effectiveness of analgesics, enhancing client control of pain.
2. Assess client’s verbal and nonverbal pain cues.
Rationale: Discrepancy between verbal and nonverbal cues may provide clues to degree of pain and need for and effectiveness of interventions.
3. Note possible pathophysiological and psychological causes of pain.
Rationale: Fear, distress, anxiety, and grief over confirmed diagnosis of cancer can impair ability to cope. In addition, a posterolateral incision is more uncomfortable for client than an
anterolateral incision. The presence of chest tubes can greatly increase discomfort.
4. Evaluate effectiveness of pain control. Encourage sufficient medication to manage pain; change medication or time span as appropriate.
Rationale: Pain perception and pain relief are subjective, thus pain management is best left to client’s discretion. If client is unable to provide input, the nurse should observe physiological and nonverbal signs of pain and administer medications on a regular basis.
5. Encourage verbalization of feelings about the pain.
Rationale: Fears and concerns can increase muscle tension and lower threshold of pain perception.
6. Provide comfort measures such as frequent changes of position, back rubs, and support with pillows. Encourage use of relaxation techniques including visualization, guided imagery, and appropriate diversional activities.
Rationale: Promotes relaxation and redirects attention. Relieves discomfort and augments therapeutic effects of analgesia.
7. Schedule rest periods; provide quiet environment.
Rationale: Decreases fatigue and conserves energy, enhancing coping abilities.
8. Assist with self-care activities, breathing, arm exercises, and ambulation.
Rationale: Prevents undue fatigue and incisional strain. Encouragement and physical assistance and support may be needed for some time before client is able or confident enough to perform
these activities because of pain or fear of pain.
9. Assist with patient-controlled analgesia (PCA) or analgesia through epidural catheter. Administer intermittent analgesics routinely, as indicated, especially 45 to 60 minutes
before respiratory treatments, and deep-breathing and coughing exercises.
Rationale: Maintaining a constant drug level avoids cyclic periods of pain, aids in muscle healing, and improves respiratory function and emotional comfort and coping.
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