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Pain

Assessment
Subjective:
ang sakit sakit ng
dibdib at ulo ko!! as
verbalized by the
patient

Objective:
> Facial grimace
> Weakness in
appearance
> Restlessness
> Coldy clammy skin
> Pain scale: 10/10
> Vs taken as

follows:
T: 37C
PR: 89pbm
RR: 23
BP: 140/80mmHg

Planning
After 8 hours of nursing
intervention,the patient will
experience decrease pain as
evidence by: verbalization of
decrease pain,relaxe facial
expression and body
positioning,increased
participation in activities and
stable vital signs.

Intervention
Assess pain reports, noting location, intensity (010
scale), frequency, and time of onset. Note
nonverbal cues like restlessness, tachycardia,
grimacing.
Instruct and encourage patient to report pain as it
develops rather than waiting until level is severe.
Encourage verbalization of feelings.
Provide diversional activities: provide reading
materials, light exercising, visiting, etc.

Scientific Rationale
Indicates need for or effectiveness of interventions and
may signal development or resolution of
complications. Chronic pain does not produce
autonomic changes; however, acute and chronic
pain can coexist.
Efficacy of comfort measures and medications is
improved with timely intervention.
Can reduce anxiety and fear and thereby reduce
perception of intensity of pain.
Refocuses attention; may enhance coping abilities.

Perform palliative measures: repositioning, massage, Promotes relaxation and decreases muscle tension.
ROM of affected joints.
Promotes relaxation and feeling of well-being. May
Instruct and encourage use of visualization, guided
decrease the need for narcotic analgesics (CNS
imagery, progressive relaxation, deep-breathing
depressants) when a neuro/motor degenerative
techniques, meditation, and mindfulness.
process is already involved. May not be successful
in presence of dementia, even when dementia is
minor.
Provide oral care.

Oral ulcerations and lesions may cause severe


discomfort.

Apply warm or moist packs to pentamidine injection


and IV sites for 20 min after administration.

These injections are known to cause pain and sterile


abscesses

Administer analgesics and/or antipyretics, narcotic


Provides relief of pain and discomfort; reduces fever.
analgesics. Use patient-controlled analgesia (PCA)
PCA or around-the-clock medication keeps the
or provide around-the-clock analgesia with rescue
blood level of analgesia stable, preventing cyclic
doses prn.
under medication or overmedication. Drugs such as
Ativan may be used to potentiate effects of
analgesics.

Evaluation
After 8 hours of
nursing
intervention,the
patient was able to
experience decrease
pain as evidenced
by: verbalization of
decrease pain,relaxe
facial expression and
body
positioning,increased
participation in
activities and stable
vital signs.