1 Acute Pain: head, throat, sinus related to inflammation of the nose
Goal : Pain is reduced or lost
Expected outcomes are:
- Clients express the pain diminished or disappeared
- Clients do not grimace in pain
1. Assess client's level of pain
R :/ Knowing the client's level of pain in determining further action
2. Explain the causes and effects of pain on the client and family
R :/ With the causes and consequences of pain the client is expected to participate in treatment to reduce pain
3. Teach relaxation techniques and distractions
R :/ The client knows the distraction and relaxation techniques can be practiced so as if in pain
4. Observation of vital signs and client complaints
R :/ Knowing the general state and development of the client's condition.
2. Anxiety related to lack of client knowledge about diseases and medical procedures (sinus irrigation / operation)
Goal: Anxiety is reduced / lost
Expected outcomes are:
- Clients will describe the level of anxiety and coping patterns.
- The client knows and understands about his illness and its treatment.
1. Assess client's level of anxiety
R :/ Determining the next action
2. Give comfort and ketentaman on the client:
- Show empathy (it comes with a touch client)
3. Give an explanation to clients about the illness slowly, quietly and use of clear sentences, short easy to understand
R :/ Increase client understanding about the disease and therapies for the disease so that the client more cooperative
4. Get rid of excessive stimulation such as:
- Place the room quieter client
- Limit contact with others / other clients are likely to experience anxiety
3. Ineffective Airway Clearance related to the obstruction (nasal secret buildup) secondary to inflammation of the sinuses
Goal: Effective airway, after a secret (seous, purulent) issued
Expected outcomes are:
- Clients no longer breathe through the mouth
- Airway back to normal, especially the nose
1. Assess the existing build-secret
R :/ Knowing the severity and subsequent action
2. Observation of vital signs
R :/ Knowing the client's development prior to surgery
3. Collaboration with the medical team for cleaning discharge
R :/ cooperation to eliminate the buildup of secret / problem