CUES
NURSING DIAGNOSIS
INFERENCES
Acute cute pain pain Unrelieved Patient related to acute pain leads verbalized physical to debilitation, “Masakit agent and diminished yung tuhod inflammatory quality of life, ko, yung process and depression. parte na secondar secondary y to Unrelieved may inse insert rtio ion n of acute nakatusok,” Steinmann postoperative - Verbalized pin and pain leads to “Namaman pre prese senc ncee of development of hid yung arthritis chronic pain tuhod ko, respectively syndromes and parang may increased tumutusok, complications. pasumpong In fact, -sumpong unrelieved pain sya.” can kill. - Verbalized “Mas Source: masakit MedicalSurgical yung rayuma ko Nursing, 7 th ed. by Black, Joyce sa kaliwang kamay, M. and Jane pasumpong Hokanson -sumpong Hawks; p. 440 sya.” - Verbalized “Masakit
SUBJECTIVE:
-
PLANNING
GOAL:
NURSING INTERVENTIONS INDEPENDENT:
After 8 hours of 1. Inst Instru ruct ct cli clien entt to nursing report any interventions, interventions, the improvement/exac patient will be er-bation in pain able to experience experience. gradual reduction/relief reduction/relief of pain.
RATIO NA NALE
INDEPENDENT:
EFFECTIVENESS:
1.
Unre Unreli liev eved ed pain pain can create other problems such as anger, anxiety, immobility, respiratory problems, and delay in healing. (Medical-Surgical Nursing, 7 th ed. by Black, Joyce M. and Jane Hokanson Hawks; p. 443)
Was the patient able to experience gradual reduction/relief reduction/relief of pain after 8 hours of nursing interventions? __yes why?
Only Only the the cli clien entt can can judge the level and distress of pain; pain management should be a team approach that includes the client. Very few people lie about pain. (Medical-Surgical Nursing, 7 th ed. by Black, Joyce M. and Jane Hokanson Hawks;
Was the patient able to have normal respiratory rate after the series of nursing interventions?? __yes why?
OBJECTIVES:
After the series of nursing interventions, interventions, the patient will be able to: 2. 1.
verbal rbaliz izee reduction/ relief of pain.
2.
have have norm normal al Respiratory Rate.
3.
move move his his lef leftt upper extremity without facial grimace
Enc Encoura ourag ge verbalization of feelings about the pain.
EVALUATION
2.
Was the patient able to verbalize reduction/relief reduction/relief of pain after the series of nursing interventions? interventions? __yes why?
Was the patient able to move his left upper extremity without facial grimace after the series of nursing interventions? interventions? __yes why?
__no
__no
__no
__no
yung rayuma ko lalo na pag ginagalaw ko; lagi syang kumikirot.” OBJECTIVE:
-
-
-
-
Pain scale of 10 for arthritis on left wrist Pain scale of 2 for site of Steinmann pin insertion RR: 21 cpm Exhibited facial grimace upon movement of the left upper extremity Exhibited facial grimace upon
Etiology of Acute Pain from the Site of Steinmann Pin Insertion: Immediate cause:
p. 443) 4.
5.
Activation of nociceptors or pain receptors 6. Intermediate cause:
Break in the skin integrity
have have no faci facial al grimace upon palpation of the wrist
3.
reci recitte th the nonpharmacol ogic ways to lessen pain. demo demons nstr trat atee the nonpharmacol ogic ways to lessen pain.
4.
Prov Provid idee comf comfor ortt 3. To pro provi vide de measures such as nonpharmacologic use of incentive pain management. (Nurse’s Pocket spirometry or blow bottles. Guide, 9th ed. by Doenges, Marilynn, et.al., p. 368) Enc Encoura ourag ge relatives to perform touch therapy.
4.
Root cause:
Insertion of Steinmann pin Etiology of Pain on Left Wrist: Immediate cause:
Activation of nociceptors or pain receptors Intermediate cause:
The The hum human an body body is believed to have energy fields that express aberrant patterns when body systems are insulted. Therapeutic Touch is thought to realign aberrant fields. (Medical(MedicalSurgical Nursing, 7 th ed. by Black, Joyce M. and Jane Hokanson Hawks; p. 480)
Was the patient able to have no facial grimace upon palpation of the wrist after the series of nursing interventions? interventions? __yes why? Was the patient able to recite the nonpharmacologic ways to lessen pain after the series of nursing interventions? __yes why? Was the patient able to demonstrate the nonpharmacologic ways to lessen pain after the series of nursing interventions? __yes why?
__no
__no
__no
EFFICIENCY:
5.
Enco Encour urag agee and and assist client to do deep breathing exercises.
5.
Deep Deep breath breathing ing for relaxation is easy to learn and contributes to pain relief and/or
Were the human resources, materials and time used economically? __yes why?
__no
palpation of the wrist
Inflammatory process Root cause:
Presence of an underlying disease/ condition (Rheumatoid and Gouty arthritis)
reduction by APPROPRIATENESS: reducing muscle tension and Were the interventions anxiety. (Medical(Medicalsuitable to client’s Surgical Nursing, situation? 7 th ed. by Black, __yes Joyce M. and Jane why? Hokanson Hawks; p. 479) Were the setting and 6. Provide 6. If the the cli clien entt is ill ill,, time table interventions interventions psychological ascertain the realistic to client’s support/motivation motivation for situation? . returning to an __yes optimal level of why? wellness. (Medical-Surgical ACCEPTABILITY: Nursing, 7 th ed. by Were the interventions Black, Joyce M. accepted by the patient and Jane (without any signs of Hokanson Hawks; rejection from the patient p. 75) and family members)? __yes 7. Enc Encoura urage 7. To prom promot otee why? mobilization of the circulation and ADEQUACY: left upper prevent excessive extremity. Assist tissue pressure. Was the number of with ROM ( Fundamentals Fundamentals of interventions interventions sufficient exercises. Nursing 7 th ed. by to meet the desired goal Kozier, Barbara, p. and objectives? 535) __yes why? 8. Enc Encoura urage 8. To prev prevent ent fatigu fatigue. e. adequate periods (Nurse’s Pocket
__no
__no
__no
__no
of rest and sleep, including uninterrupted periods of sufficient duration, meeting comfort needs, limiting/ avoiding use of caffeine/ alcohol and medications affecting REM sleep. Encourage quiet, restful atmosphere.
Guide, 9th ed. by Doenges, Marilynn, et.al., p. 369)
9. Disc Discus usss wit with h relatives the importance of early detection and reporting of changes in condition or any unusual physical discomforts/ changes.
9. Prom Promot otes es early early detection of developing complications. Fundamentals of ( Fundamentals Nursing 7 th ed. by Kozier, Barbara, p. 536)
10. Teach Teach the client and significant others about the nonpharmacologic ways to lessen pain.
10. It may be possible possible to teach clients a combination of these techniques to maximize their opportunities for self-control over
manifestations of pain. (Medical( MedicalSurgical Nursing, 7 th ed. by Black, Joyce M. and Jane Hokanson Hawks; p. 476)
11. Notify physician if regimen is inadequate.
11. To meet pain pain control goal. (Nurse’s Pocket Guide, 9th ed. by Doenges, Marilynn, et.al., p. 368) COLLABORATIVE:
COLLABORATIVE:
1. Admi Admini nist ster er medications (particularly analgesics) as prescribed.
1.
Nece Necess ssar ary y for for treatment of the underlying cause. (Nurse’s Pocket Guide, 9th ed. by Doenges, Marilynn, et.al., p. 542) To maintain acceptable level of pain. (Nurse’s Pocket Guide, 9th ed. by Doenges, Marilynn, et.al., p. 368) 2. To det deter ermi mine ne changes indicative
2. Assi Assist st with with laboratory/diagnos tic studies as indicated. (e.g., Chest Ultrasound).
of healing/ infection/ complications. To identify causative/precipitating factors. (Nurse’s Pocket Guide, 9th ed. by Doenges, Marilynn, et.al., p. 70)
XI. NURSING CARE PLANS
