Friday, October 16, 2015

Nursing Care Plan for Hyphema : Acute Pain

Hyphema or blood in the anterior chamber can occur due to blunt trauma (Sidarta, 1998). When the patient is sitting, hyphema will be seen to collect in the bottom of the anterior chamber and hyphema can occupy the entire space anterior chamber. Blood in the aqueous humor fluid can form a layer that is visible. This type of injury does not have to lead to perforation of the eyeball.

Acute pain related to exposure of pain receptors secondary to blunt trauma.

Goal: The pain is reduced

Expected outcomes:
  • The patient demonstrated knowledge of pain control.
  • The patient experience and demonstrate a period of sleep is not disturbed.
  • The patient expresses pain decreased with mild pain scale (1-3).
  • Assess the type, intensity and location of pain.
  • Use pain scale levels to determine the dose of analgesics.
  • Maintain bed rest in an upright position or the position of head of 60ยบ.
  • Perform eye bandage on the affected part.
  • Give a cold compress to reduce pain and swelling.
  • Give sedation to minimize activity.
  • Collaboration: Giving therapy to reduce pain.
  • Give a back rub, a change of position for
  • increase comfort.
  • Help teach relaxation techniques.

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