NCP 2: Acute Pain related to irritation of the pleural space as evidenced by chest pain and headache (Figure 10)

ASSESSMENT EXPLANATION OF THE OBJECTIVES NURSING RATIONALE EVALUATION

PROBLEM INTERVENTIONS

Subjective: The pleural fluids that STO: Dx: STO:

was accumulated
"sumasakit po ang irritated the pleural Within 3 hours of effective  Noted client’s age  Affecting ability to (Goal Met)
dibdib ko. Parang space that can cause nursing interventions, the and report pain
tinutusok po. patients’ rate of pain will developmental parameters Within 3 hours of effective nursing
internal pain which interventions, the patient pain
Minsan nawawala radiates to the chest. decrease from 6/10 to 3/10 level and current
tapus biglang condition decreases from 6/10 to 3/10
sasakit po ulit. ".  To help determine
 Assessed for
Objective: SOURCE/S: LTO: referred pain, as possibility of underlying
condition or organ LTO:
Within 3 days of effective appropriate
 Guarding www.nurseslab.com dysfunction requiring
nursing interventions, the (Goal Met)
behavior and treatment
positioning to patient will demonstrate Within 3 days of effective nursing
avoid pain nonpharmacologic methods
interventions, the patient
 Irritable and that provide relief of pain. demonstrated nonpharmacologic
 Noted patients  Individual with external
sighing locus of control locus of control may methods that provide relief of pain
(external or take little or no such as deep breathing or focusing
Nursing Diagnosis: breathing, listening to music and
internal) responsibility for pain
Acute Pain related management communicating with the significant
to accumulation others.
of fluid in the  Obtained
pleural space as patient’s/ SO’s  In order to fully
evidenced by assessment of pain understand client’s
chest pain and to include
headache location, pain symptoms.
characteristic,
onset, duration,  Observations may not
frequency, quality, be congruent with
intensity. Identified verbal reports or may
precipitating or be only indicator
aggravating and present when client is
relieving factors. unable to verbalize.

 Observed
nonverbal cues  Verbal and/or
and pain
behavioral cues may
behaviors; and have no direct
other objective relationship to the
defining degree of pain
characteristics, as perceived.
noted, especially
in person who
cannot
communicate  Which are usually
verbally. altered in acute pain.

 One client may not be

100% pain free but
 Noted cultural and -may feel that a “3” is
developmental a manageable level of
influences discomfort, while
affecting pain another may require
response. medication for pain at
the same level,
because the
experience is
 subjective.

 Monitored skin  To medicate

color and prophylactically, as
temperature and appropriate.
vital signs.

 Determined
client’s  To reduce concern of
acceptable level the unknown and
of pain and pain associated muscle
control goals. tension.

 To promote
nonpharmacological
pain management.

 Noted when pain

occurs.
 Aids in control of chest
discomfort while
enhancing the
effectiveness of cough
 Reviewed effort.
procedures and
expectations
including when
treatment may  To distract attention
cause pain and reduce tension.
Tx:

 Provided comfort  To evaluate coping

measures such as; abilities and to identify
repositioning, areas of additional
quiet concern.
environment, and
calm activities.  To prevent fatigue that
can impair ability to
 Assisted patient in manage or cope with
chest splinting pain.
techniques during
coughing
episodes.

Edx:

 Instructed in and
encouraged used
of relaxation
techniques such
as focused
breathing,
listening to music
or communicating
with SO.

 Encouraged
 verbalization of
feeling about the
pain such as
concern about
tolerating pain,
anxiety, pessimistic
thoughts.

 Encouraged
adequate rest
periods