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    NCP - Acute Pain

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    ryan
    Date: NURSING DIAGNOSIS 1. Acute pain related to cardiac ischemia as evidenced by pain score of 9/10, sleep disturbance, and distraction behavior. 2. Risk for impaired gas exchange related to decreased cardiac output and increased oxygen demand as evidenced by chest pain. 3. Readiness for enhanced comfort measures related to pain management as evidenced by verbalization of desire for pain relief. GOALS 1. Patient will verbalize relief of chest pain within 1 hour of analgesic administration. 2. Patient will follow prescribed pharmacological regimen. 3. Patient will verbalize use of nonpharmacological methods that provide relief. 4. Patient will demonstrate

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    NCP - Acute Pain

    Uploaded by

    ryan
    3K views5 pages
    Date: NURSING DIAGNOSIS 1. Acute pain related to cardiac ischemia as evidenced by pain score of 9/10, sleep disturbance, and distraction behavior. 2. Risk for impaired gas exchange related to decreased cardiac output and increased oxygen demand as evidenced by chest pain. 3. Readiness for enhanced comfort measures related to pain management as evidenced by verbalization of desire for pain relief. GOALS 1. Patient will verbalize relief of chest pain within 1 hour of analgesic administration. 2. Patient will follow prescribed pharmacological regimen. 3. Patient will verbalize use of nonpharmacological methods that provide relief. 4. Patient will demonstrate

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    acute pain, nursing care plan

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    3. NCP - Acute Pain

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    Date: NURSING DIAGNOSIS 1. Acute pain related to cardiac ischemia as evidenced by pain score of 9/10, sleep disturbance, and distraction behavior. 2. Risk for impaired gas exchange related to decreased cardiac output and increased oxygen demand as evidenced by chest pain. 3. Readiness for enhanced comfort measures related to pain management as evidenced by verbalization of desire for pain relief. GOALS 1. Patient will verbalize relief of chest pain within 1 hour of analgesic administration. 2. Patient will follow prescribed pharmacological regimen. 3. Patient will verbalize use of nonpharmacological methods that provide relief. 4. Patient will demonstrate

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    Download as doc, pdf, or txt
    3K views5 pages

    NCP - Acute Pain

    Uploaded by

    ryan
    Date: NURSING DIAGNOSIS 1. Acute pain related to cardiac ischemia as evidenced by pain score of 9/10, sleep disturbance, and distraction behavior. 2. Risk for impaired gas exchange related to decreased cardiac output and increased oxygen demand as evidenced by chest pain. 3. Readiness for enhanced comfort measures related to pain management as evidenced by verbalization of desire for pain relief. GOALS 1. Patient will verbalize relief of chest pain within 1 hour of analgesic administration. 2. Patient will follow prescribed pharmacological regimen. 3. Patient will verbalize use of nonpharmacological methods that provide relief. 4. Patient will demonstrate

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    The key takeaways are about assessing and managing a patient's acute chest pain which is likely due to angina or increased cardiac workload. Nursing interventions focus on relieving pain, monitoring the patient, and administering appropriate medications.

    Nursing interventions for acute chest pain include instructing the patient to notify the nurse when pain occurs, assessing and documenting the patient's response to medications, observing for associated symptoms, evaluating reports of pain radiating to other areas, placing the patient at rest during episodes, and monitoring ECG changes.

    Medications used to treat angina mentioned are nitroglycerin, beta-blockers, calcium channel blockers, and morphine sulfate which can be used for acute onset due to its analgesic effects.

    CUES

    NURSING
    DIAGNOSIS

    SCIENTIFIC
    BASIS

    GOALS
    &OUTCOME
    CRITERIA

    NURSING
    ACTIONS AND
    NURSING
    ORDERS

    RATIONALE OF
    NURSING ORDERS

    EVALUATION

    SUBJECTIVE:

    Acute pain
    related to
    Mo sinyas siya increase cardiac
    kung naay sakit. workload/oxyge
    As verbalized by n consumption.
    the
    patients
    husband.

    OBJECTIVE:
    >Pain score of 9
    out of 10
    >Sleep
    disturbance
    >Distraction
    behavior

    Unpleasant sensory
    and
    emotional
    experience arising
    from actual or
    potential
    tissue
    damage or describe
    in terms of such
    damage. Sudden or
    slow onset of any
    intensity from mild
    to severe with an
    anticipated
    or
    predictable end and
    a duration of less
    than six months.

    After 8 hours of
    nursing
    interventions the
    patient will be able
    to:
    Relieve
    within 1
    hour of
    analgesic
    administrati
    on.
    Follow
    prescribed
    pharmacolo
    gical
    regimen.

    INDEPENDENT:
    >Instruct client to
    notify nurse
    immediately when
    chest pain occurs.

    >Assess and
    document client
    response/effects of
    medication.

    >Observe for
    associated
    symptoms e.g,
    dyspnea,
    Verbalize
    nausea/vomiting,
    nonpharmac dizziness,
    ologic
    palpitations, desire
    methods that to macturate.
    provide
    relief.
    Demonstrate
    use of
    relaxation
    skills and

    >Evaluate reports of
    pain jaw, neck,
    shoulder, arm, or
    hand.

    -Pain and decreased cardiac


    output may stimulate the
    sympathetic nervous system
    to release excessive
    amounts of norepinephrine,
    which increases platelet
    aggregation and release of
    thromboxane A2.
    -Provides information about
    disease progression.

    -Decreased cardiac output


    stimulates
    sympathetic/parasympatheti
    c nervous system.

    -Cardiac pain may radiate;


    e.g, pain is often referred to
    more superficial sites
    served by the same spinal

    After 8 hours of
    Nursing interventions
    the patient was able
    to:
    Relieved
    within 1 hour
    of analgesic
    administration
    .
    Followed
    prescribed
    pharmacologic
    al regimen.
    Verbalized
    nonpharmacol
    ogic methods
    that provide
    relief.
    Demonstrated
    use
    of
    relaxation
    skills
    and
    diversional
    activities, as
    indicated, for
    individual

    diversional
    activities, as
    indicated,
    for
    individual
    situation.

    >Place client at
    complete rest
    during angina
    episodes.
    DEPENDENT:

    and cord nerve level.


    - Reduces myocardial
    oxygen demand of
    minimize risk of tissue
    injury/necrosis.

    >Administer
    antianginal
    medications
    promptly as
    indicated:

    Nitroglyceri
    n

    B-blockers

    -Nitroglycerin has been the


    standard for treating and
    preventing anginal pain for
    more than 100 years.
    -Reduce angina by reducing
    the hearts workload.

    Calcuim
    channel
    blockers

    Morphine
    sulfate

    -Produce relaxation of
    coronary vascular smooth
    muscle, dilate coronary
    arteries; decrease peripheral
    vascular resistance.
    -Potent narcotic analgesic
    may be used in acute onset
    because of its several

    situation.

    >Monitor serial
    ECG changes.
    ( Marilynn E.
    Doenges NCP 7th
    Edition)

    beneficial effects.
    -Ischemia during angina
    attack may cause transient
    ST segment depression or
    elevation and T wave
    inversion.
    (Marilynn E. Doenges NCP
    7th Edition)

    NURSING CARE PLAN

    Patients Name:
    Age:

    Hospital No.:
    Room No.:

    CLINICAL PORTRAIT

    Impression:
    Nurses Name & Signature:

    PERTINENT DATA

    Physician:

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