NCP Acute Pain NCS

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X.III NURSING CARE PLAN ASSESSMENT NURSING DIAGNOSIS Acute pain related to insufficiency of oxygen to the myocardium as evidenced by the occasional mild to moderate chest pain on the left anterior chest wall with pain scale of 6-7 described as heavy or squeezing, with facial grimacing, with mild attack around 9:20 AM December 13, 2011, Levines sign present and slight labored breathing noted DESIRED OUTCOME/ NURSING GOALS Predisposing After 8 hours of factors: nursing Age: 43 years interventions, the client will be able old Gender: female to: With family history of heart 1. Report pain is diseases relieved/ controlled. Precipitating Factors: Hypertensive HDL less than normal value; LDL more than the normal value Does not exercise regularly High fat diet RATIONALE NURSING INTERVENTIONS JUSTIFICATION EVALUATION
Actual Abnormal Cues: With complaints of occasional, mild to moderate chest pain on the left anterior chest wall with pain scale of approximately 6-7 described as heavy and squeezing Ordered to be on complete bed rest with no bathroom privileges With facial grimacing noted With O2 on standby With mild chest discomfort with pain scale of 7 around 9:20 AM December 13, 2011, Levines sign present and
Independent Nursing Interventions:
After 8 hours of nursing interventions, the client was able to:
a. Perform a comprehensive assessment for pain b. Perform pain assessment everytime pain occurs; note and investigate changes c. Monitor vital signs d. Observe nonverbal cues
-to assess etiology, precipitating and contributory factors of pain
Build-up of fatty clumps and plaques in the coronary arteries
2. Verbalize methods that provide relief
a. Encourage verbalization of feelings about the pain. b. Review clients previous experiences of pain and methods found either helpful or unhelpful for
1. Goal met. Client was able to verbalize that the chest discomfort that she felt around 9:20 AM decreased and subsided -to rule out worsening of more or less after 15 underlying minutes. Her vital signs condition/development of that were taken upon the complications attack were as follows: BP=130/90 mmHg and -usually altered in acute PR= 106 bpm. An hour pain after the attack the blood pressure was 110/80 -observations may/may mmHg, pulse rate was 82 not be congruent with bpm and respiratory rate verbal reports indicating was 19 cpm with no need for further evaluation presence of labored breathing. -to assist client to explore methods for alleviation/ control of pain. -to evaluate clients 2. Goal met. Client was able to disclose to student nurses that the oxygen usually helped her decrease
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slight labored breathing noted Risk Factors/Weaknesse s: Deficient knowledge of medications Stress brought by financial expenses of hospitalizati ons Wellness/Strengths: Support from family Good financial resources Strong religious beliefs
Definition: Unpleasant sensory and emotional experiences arising from actual to potential tissue damage; sudden onset of of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months
pain control Coronary arteries become narrower c, Provide quiet environment and calm activities A clump of fat in the artery tears open A blood clot forms on the tear The clot partly/completely blocks the artery Decreased supply of oxygen and 3. Follow nutient-rich blood prescribed therapeutic regimen Aerobic mechanism switched to anaerobic mechanism Build-up of lactic acid and metabolic wastes d. Provide comfort measures (e.g. change of positions)
response to pain
-to lessen stimulation of pain -to provide nonpharmacological interventions to alleviate pain -to explore methods to alleviate pain -to increase the methods of alleviating pain in a nonpharmacological way
pain, as well as the medications that she took. She said that her husband is careful and quiet around her so that she wouldnt be stressed. She usually slept, hoping that it would decrease the chances of pain.
e. Encourage diversional activities f. Encourage relaxation techniques and exercises
a. Discuss with the client what the nature of angina is and its risk factors in a less stressful manner a. Discuss with client the medications prescribed by the physician b. Discuss the contents of the student nurses health teaching plan that contain lifestyle changes and behaviors with client Collaborative interventions:
-to give further understanding of clients situation without harming her
3. Goal met. Client was able to realize the severity of the problem after finding out that the chest -to increase clients discomfort may happen compliance to medications even if at rest. She then promised to herself that she -to increase clients will be compliant to her awareness of the things medications. She also that can still be done to disclosed to her student achieve optimum level of nurses her difficulty in functioning keeping up with her medications, stating, kadamo abi sang mga
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Source: Doenges, et al. Nurses Pocket Guide (9th ed.). F.A. Davis Company.200 4. p 365.
Tissue damage Acute pain
a. Administer prescribed medications (e.g. antianginals, antihypertensives, antilipidemics) b. Administer supplemental oxygen if required
-to treat the clients condition with pharmacological way -to increase oxygenation in the body; to decrease pain
bulong ko, kabudlay imaintain pero kayanon ko nalang.
occasional mild to moderate chest pain on the left anterior chest wall with pain scale of 6-7 described as heavy or squeezing Source: National Heart, Lung and Blood institute. (June 2011). Unstable angina. http://www.nhlbi. nih.gov/health/he althtopics/topics/angi na/
Source: Doenges, et al. Nurses Pocket Guide(9th ed.). F.A. Davis Company.2004. pp 366-367.

NCP Acute Pain NCS

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NCP Acute Pain NCS

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What is the client's condition?

What nursing interventions were performed?

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Independent Nursing Interventions:

After 8 hours of nursing interventions, the client was able to:

-to assess etiology, precipitating and contributory factors of pain

Build-up of fatty clumps and plaques in the coronary arteries

2. Verbalize methods that provide relief

e. Encourage diversional activities f. Encourage relaxation techniques and exercises

-to give further understanding of clients situation without harming her

Tissue damage Acute pain

bulong ko, kabudlay imaintain pero kayanon ko nalang.

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