to determine determine underlying underlying cause of pain and treat accordingly.
review regimen
2.cer 2.certa tain in drug drugs s may may fatigue and drowsiness.
medication
3. ask client to rate pain
on 0-10 0-10 scale scale (rated (rated as 9 out of 10)
Demonstrate use of diversional activities such as relaxing and/or sleeping
provide comfort meas measur ures es such such as repositioning the client in a comfortable position and providing a hot or cold compress
5.
provide calm and quie quiett envi enviro ronm nmen entt (adjust lights, temperature and elim elimin inat ate e offe offens nsiv ive e odors which may contribute to headache)
Rest and feel rested after
6. inst instru ruct cte e in relax relaxat atio ion n
Facial grimace
Evaluation statement
contri contribut buting ing factors to pain (noise, wron wrong g posi positi tion onin ing, g, environment)
4.
Rated pain as 9 out of 10
Rationale
caus cause e
to assist assist in evalua evaluatin ting g 3. impact of pain on client’s life.
to allow 4. nonpharmocological nonpharmocological pain relief and promote good circulation to the brain and decrease vasoconstriction
to 5. enviro environme nmenta ntall contr contribu ibute te to to promote rest.
decrease factor factors s which which migrai migraine ne and and
Goal met. Patient verbalized verbalized “I feel better. It’s just a little sore from all the the swel swelli ling ng.. But But it is tolerable pain.” rated pain as 4 out of 10.
Goal Goal met. met. Pati Patien entt was was able to relax relax by utilizing utilizing bed rest and deep breathing.
Goal Goal met. met. Pati Patien entt was was
adequate rest interval
BACKGROUND KNOWLEDGE: Acute pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severed with an anticipated or predictable end and a duration of less than 6 months.
techniques (deep breathing, imagery)
6.
to distract attention from pain and decrease tension
7. encrourage adequate rest periods •
•
Utilize nonpharmacological methods of pain relief ( deep breathing, guided imagery, etc)
Be able to perform ADLs as tolerated
7.
to conserve energy of the patient and prevent fatigue 8.
To promote client independence as much as possible and acquire sense of function
9.to enhance quality sleep and promote rest which harnesses energy for future use.
COLLABORATIVE:
Brunner and Suddarth’s Textbook of Medical-Surgical Nursing 11th Edition by Suzanne C. Smeltzer
Goal met. Client was able to use deep breathing and reported pain relief afterwards.
8.
SOURCE: Nurse’s Pocket Guide: Diagnoses, prioritized interventions and rationales 11th Ediction by Marilynn Doenges
able to sleep for 6 hours straight and felt rested afterwards.
1. administer medications as ordered by physician (analgesics, etc)
2.
encourage watchers to assist patient during diversional activities (minimize noise, allow
1. medications will provide synergistic effect with nonphramacologic interventions for pain relief and promote better circulation by aiding in vasodilation for better blood flow to the brain and altering prostaglandin synthesis to decrease pain 2. the significant others know the client more and will be able to aid in
Goal met. Client was to perform ADLs minimal assistance watchers (feeding, care, etc)
able with from self-
client to verbalize feelings and promote rest and sleep)
