ASSESSMENT Subjective: “Nasakit unay ti tiyan ko, lalu nu kalkalpas ko mangan.”
DIAGNOSIS Acute pain related to chemical burn of gastric mucosa
Objective: • • • • • • • •
Restless Pacing Rigid abdomen Selffocused Wrinkled nose Raised upper lips Rapid breathing Rated pain as 7/10 in a pain scale of 010
BAUTISTA, Jesther Rowen, SN IV
PLANNING After 2 hours of nursing interventions, the patient will verbalize relief from pain and rate it as 2/10 from 7/10.
INTERVENTION
RATIONALE
EVALUATION Goal met. After 2 hours of nursing interventions, the patient verbalized relief from pain and rated it as 2/10 from 7/10.
Independent: •
Assess pain characteristics (quality, severity, location, onset, duration, precipitating and relieving factors).
These data can be used to identify the extent of the pain as well as serve as a baseline information.
•
Observe or monitor signs and symptoms associated with pain, such as BP, heart rate, temperature, color and moisture of skin, restlessness, and ability to focus.
Some people deny the experience of pain when it is present. Attention to associated signs may help the nurse in evaluating pain.
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Assess for probable cause of pain.
•
Assess patient’s knowledge of or preference for the array of pain-relief strategies available.
Different etiological factors respond better to different therapies.
Some patients may be unaware of the effectiveness of nonpharmacological methods and may be
•
BAUTISTA, Jesther Rowen, SN IV
Assess patient’s willingness or ability to explore a range of techniques aimed at controlling pain.
•
Anticipate need for pain relief.
•
Respond immediately to complaint of pain.
willing to try them, either with or instead of traditional analgesic medications. Often a combination of therapies (e.g., mild analgesics with distraction or heat) may prove most effective.
Some patients will feel uncomfortable exploring alternative methods of pain relief. However, patients need to be informed that there are multiple ways to manage pain.
One can most effectively deal with pain by preventing it. Early intervention may decrease the total amount of analgesic required.
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Eliminate additional stressors or sources of discomfort whenever possible.
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Encourage small, frequent meals
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Identify and limit foods that cause discomfort such as spicy foods and carbonated drinks.
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Encourage to assume position of comfort.
Dependent: •
BAUTISTA, Jesther Rowen, SN IV
Administer analgesic for relief of pain (e.g. morphine sulfate).
In the midst of painful experiences a patient’s perception of time may become distorted. Prompt responses to complaints may result in decreased anxiety in the patient. Demonstrated concern for patient’s welfare and comfort fosters the development of a trusting relationship.
Patients may experience an exaggeration in pain or a decreased ability to tolerate painful stimuli if environmental, intrapersonal, or intrapsychic factors are further stressing them.
Small meals prevent distention and gastrin release.
•
Administer antacids (e.g. Magnesium Hydroxide Aluminum Hydroxide)
Collaborative: •
Food has acid neutralizing effect and dilutes gastric content.
Reduces abdominal tension and promotes sense of control.
Provide and implement prescribed dietary modifications. Relieves abdominal pain by reducing the peristaltic activity.
Helps relieve pain by neutralizing stomach acid and increasing bicarbonate and mucus secretion.
Patient may receive nothing by mouth initially. When oral intake is allowed, food choices will depend on BAUTISTA, Jesther Rowen, SN IV
the diagnosis.
BAUTISTA, Jesther Rowen, SN IV
