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).

Interventions:

• 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 60º.
• 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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Acute Pain and Anxiety NCP for Peritonitis

Acute Pain and Anxiety : Nursing Care Plan for Peritonitis

Nursing Diagnosis for Peritonitis: Acute Pain related to chemical irritation of the peripheral peritoneum.

Goal: reduce / eliminate the pain

Nursing Intervention:
a. Review the report of pain, record the location, duration, intensity (scale 0-10) and characteristics (shallow, sharp, constant).
Rational: the change in location / intensity is not common but may indicate the occurrence of complications.

b. Maintain semi-Fowler position as indicated
Rational: to facilitate drainage of fluids / injured because of gravity and helps minimize the pain due to movement.

c. Provide comfort measures, eg the back massage, deep breathing, relaxation exercises / visualization.
Rational: increase relaxation and may increase the patient's coping abilities by refocusing attention.

d. Give frequent mouth care. Eliminate unpleasant environmental stimuli.
Rational: reduce nausea / vomiting, which can increase the pressure / intra-abdominal pain.


Nursing Diagnosis for Peritonitis: Anxiety or fear related to the threat of death / change in health status.

Goal: to reduce or eliminate anxiety

Nursing Intervention:
a. Evaluation of anxiety levels, record verbal responses and non-verbal patients. Encourage the free expression of emotions.
Rational: fear can occur because of severe pain, increasing pain, it is important to the diagnostic procedures and possible surgery.

b. Provide information about the disease process and the anticipated action
Rational: knowing what is expected to reduce anxiety.

c. Schedule adequate rest and sleep periods stop
Rational: limiting weaknesses, save energy, and can enhance coping abilities.

Deficient Fluid Volume Nursing Care Plan for Peritonitis

Imbalanced Nutrition Less Than Body Requirements Nursing Care Plan for Peritonitis

Risk for Infection Nursing Care Plan for Peritonitis 

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COPD - Acute Pain Nursing Interventions

Nursing Care Plan for COPD - Nursing Interventions for Acute Pain

Acute pain related to the process of inflammation in the lining of the lungs

Goal: The pain is reduced / lost.

Expected outcomes are:

• Clients say the pain is reduced / lost.
• Relaxed facial expression.

Nursing Interventions - Acute Pain for COPD

1. Determine the characteristics of pain, for example; sharp, consistent, stabbed. Investigate changes in character / intensity of pain / location.
Rational: Chest pain is usually present in some degree of pneumonia, complications can arise such as pericarditis and endocarditis.

2. Monitor vital signs.
Rationale: Changes in heart rate or blood pressure showed that patients experience pain, especially when other reasons for changes in vital signs.

3. Provide comfort measures, for example: back massage, change of position, quiet music / conversation, relaxation / breathing exercises.
Rational: The act of non-analgesics administered with a gentle touch to relieve discomfort and increase the effects of analgesic therapy.

4. Offer a clean mouth often.
Rational: mouth breathing and oxygen therapy may irritate and dry the mucous memberan, potential public inconvenience.

5. Advise and assist the patient in the technique of chest compressions during episodes of coughing.
Rational: A tool to control chest discomfort while increasing the effectiveness of cough effort.

6. Give analgesic and antitussive according to indications.
Rational: This drug can be used to suppress non-productive cough / proximal or reduce excessive mucus, improve comfort / rest common.

COPD - Acute Pain Nursing Interventions

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Nursing Interventions Acute Pain related to Uterine Fibroids

Nursing Diagnosis Acute Pain related to inflammation due to the addition of mass in the uterus

Objectives:

• Pain can be reduced or lost

Expected outcomes are:

• Pain scale (1-10) = 1-3.
• Respiration = 16-24 beats / minute.
• Pulse  = 60 -100 beats / min.
• Expression showed no signs of pain and seemed to relax.

Nursing Interventions Acute Pain related to Uterine Fibroids

1. Observation of a pain scale (1-10)

Rational: Observation of a pain scale is necessary for us to know the level of pain experienced by the client so that we can provide appropriate interventions for clients.

2. Find the area, location, and intensity of pain

Rational: To determine the location of pain, pain in the abdomen may indicate the likelihood of complications

3. Give a sitting position while hugging a pillow or a position in the sense of comfort by the client

Rational: It can provide comfort to the client.

4. Give instruction in relaxation techniques and deep breathing techniques

Rational: relaxation and deep breathing techniques to increase comfort and reduce the level of pain experienced by the client

5. Encourage clients to use a warm compress

Rational: Warm compresses can increase vasodilation of blood vessels at the site of pain so that pain can be reduced.

6. Collaboration in the delivery of analgesics and antiemetics, as indicated when necessary.

Rational: The provision of analgesia is necessary if the client is a pain scale of 7-10, this analgesic increase relaxation, decrease attention to pain, and control the adverse action.

7. Provide information about the use of analgesics that are prescribed or not prescribed

Rational: The specific instructions about the use of drugs, increasing awareness of safe use and side effects.

8. Evaluation of vital signs.

Rational: To determine the condition of clients after the intervention so that it can be done to determine further action.

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Acute Pain / Chronic Pain - Rheumatoid Arthritis Nursing Care Plan

Rheumatoid Arthritis

Rheumatoid Arthritis (RA) is a chronic inflammation of the joints. This disease is categorized as an autoimmune disease because people suffering from this condition have antibodies in their blood that target their own body tissues.

Rheumatoid arthritis can attack various organs and tissues in the human body. However, it mainly attacks synovial joints in the hands, wrists, ankles, and knees.

There are, typically, three distinctive types of discomfort which go along with chronic RA. The foremost of these types of discomfort is often called "flair up pain." It is caused by the inflammation of the joints which goes along with periods when your RA is flaring and active.

The next type of rheumatoid pain is often simply called joint pain. It is caused by damage to the joints, which is a consequence of the inflammation. This is the everyday discomfort which is present, even while your RA is not active.

Finally, the very last rheumatoid aspect of the pain equation might be called "emotional pain." It involves the emotions, your psychological well being, and your stress level. The tiredness which you will feel is a part too. This aspect of RA really makes "everything hurt worse."

Management / Treatment of Rheumatoid Arthritis

Nursing Care Plan for Rheumatoid Arthritis

Nursing Diagnosis for Rheumatoid Arthritis : Acute Pain / Chronic Pain

related to:

• Tissue distension by accumulation of fluid / inflammatory process
• Destruction of joints.

Can be evidenced by:

• Complaints of pain, discomfort, fatigue.
• Focusing on self / narrowing of focus
• Behavior distraction / autonomic response
• Behavior that is care / protect

Expected results / patient evaluation criteria will be:

• Showed pain relief / control
• Looks relaxed, able to sleep / rest and participate in activities according to ability.
• Follow the program prescribed pharmacological
• Combining the skills of relaxation and entertainment activities into a program of pain control.

Nursing Interventions and Rational - Nursing Care Plan for Rheumatoid Arthritis

1. Record complaints of pain, record the location and intensity (scale 0-10). Write down the factors that accelerate and signs of pain - non-verbal.

Rational: To assist in determining the need for pain management and program effectiveness.

2. Give a hard mattress, a small pillow. Elevate the bed linen as needed.

Rational: a soft mattress, pillow that would prevent maintenance of proper body alignment, placing stress on the joints that hurt. Elevation of the bed linen lowering the pressure in the inflamed joints / pain.

3. Place / monitor the use of pillows, sandbags, splint, brace.

Rational: Resting sore joints and maintain a neutral position. The use of the brace can reduce pain and can reduce damage to the joints.

4. Advise to change position frequently. Help to move in bed, prop joint pain above and below, avoid jerky movements.

Rationale: Prevent the occurrence of general fatigue and joint stiffness. Stabilize joints, reduce the movement / pain in the joints.

5. Instruct the patient to a warm bath or shower at the time awake and / or at bedtime. Provide a warm washcloth compress for sore joints several times a day. Monitor the temperature of the water compresses, baths, and so on.

Rational: The heat increases muscle relaxation, and mobility, reduce pain and stiffness in the morning release. Sensitivity to heat can be removed and dermal wound can be healed.

6. Give a gentle massage

Rationale: Increase relaxation / reducing pain.

7. Encourage the use of stress management techniques, such as progressive relaxation, therapeutic touch, biofeed back, visualization, guidelines imagination, self hypnosis, and breath control.

Rationale: Increase relaxation, provide a sense of control and may enhance coping abilities.

8. Engage in activities appropriate entertainment for individual situations.

Rationale: Focusing attention back, providing stimulation, and increased self-confidence and feeling healthy.

9. Give drug before the activity / planned exercise as directed.

Rationale: Increasing realaksasi, reduce muscle tension / spasm, making it easier to participate in therapy.

10. Collaboration: Give medications as directed.

Rational: As an anti-inflammatory and mild analgesic effect in reducing stiffness and increasing mobility.

11. Give ice-cold compress if needed

Rational: The cold can relieve pain and swelling during the acute period

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Acute Pain Nursing Care Plan for Pyelonephritis

Pyelonephritis or a kidney infection usually caused by Escherichia Coli, a bacteria type that is found in the large intestine. This infection makes its way from the genital area through the urethra to the bladder, up the ureters and then it reaches the kidneys. Being more common in women than in men.

Pyelonephritis known that if a person has any physical obstruction to the flow of urine, like a kidney stone, an enlarged prostate, or the backflow of urine from the bladder into the ureters, it is very likely the risk of pyelonephritis to rise.

Persons with pyelonephritis might experience painful urination, tightly contraction of the abdomen muscles, one or both kidneys may be enlarged and tender, and cystitis symptoms can appear also. Usually, pyelonephritis starts suddenly, with pain in the lower part of the back on either side, fever, chills, nausea and vomiting, but very often, in children these symptoms are slight and difficult to recognize.

Nursing Care Plan for Pyelonephritis

Nursing Diagnosis for Pyelonephritis : Acute Pain related to inflammation and infection of the urethra, bladder and other urinary tract structures.

Evaluation criteria: no pain when urinating, no pain on percussion of the pelvis.

Nursing Interventions and Rational for Pyelonephritis

Independent

1. Monitor urine output to changes in color, odor and voiding pattern, input and output every 8 hours and monitor the results of repeated urinalysis.

Rational: To identify indications of progress or deviations from expected results.

2. Record the location, duration, intensity scale (1-10) the spread of pain.

Rational: To help evaluate the obstroksi and cause pain.

3. Provide comfort measures, such as back massage, environment, rest, sleep.

Rational: Increase relaxation, reduce muscle tension.

4. Help or encourage the use of focused relaxation breathing.

Rational: Helps to redirect attention and for muscle relaxation.

5. Give perianal care.

Rational: To prevent contamination of the urethra.

6. If mounted catheter, catheter care provided 2 times per day.

Rational: The catheter provides a way for bacteria to enter the bladder and up into the urinary tract.

Collaboration

1. Consul doctor if: previous urine yellow, ivory, yellow urine, dark orange, hazy or cloudy. Micturition pattern changes, frequent urination in small amounts, feeling the urge to urinate. Persistent pain or increasing pain.

Rational: These findings could signal further tissue damage and needs extensive examination.

2. Give analgesics as needed and evaluate its success.

Rational: Analgesic block the path of pain, thereby reducing pain.

3. Giving antibiotics. Create a variety of drink preparations, including fresh water. Provision of water to 2400 ml / day.

Rational: As a result of urine output makes it easy to urinate often and help flush urinary tract. 

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Acute Pain Nursing Care Plan for Hepatitis

Hepatitis is characterized by the destruction of a number of liver cells and the presence of inflammatory cells in the liver tissue caused by excessive alcohol drinking, disorders of the gall bladder or pancreas, including medication side effects, and infections.

A person can develop hepatitis if they contract one of the viruses that can cause liver inflammation, or as a result of exposure to substances that can cause hepatitis. There are two ways that can lead to hepatitis: it can either occur as a result of infections or from autoimmune processes.

Hepatitis can be divided into two subgroups:

1. Acute Hepatitis
Acute hepatitis caused by the below in result of inflammation that causes damaging to the liver's normal function and lasting less than six months. People having a weakened immune system and weaken liver, making them more susceptible to be infected by hepatitis.
a) Infectious viral hepatitis such as hepatitis A, B, C, D, E.
b) Inflammation of liver caused by Epstein-Barr virus and cytomegalovirus.
c) Inflammation of liver caused by other bacteria.
d) Medication overdose causing damage to liver tissues and cells such as tranquilizers, chemotherapeutic agents, antibiotics and anesthetics.
e) Excessive alcohol drinking.

2. Chronic Hepatitis:
Chronic hepatitis means active, ongoing inflammation of the liver persisting for more than six months. Chronic hepatitis, although much less common than acute hepatitis, can persist for years, even decades. In most people, it is quite mild and does not cause significant liver damage. It may be caused by hepatitis B and C viruses, drugs and excessive alcohol drinking. It can also result in cirrhosis, with an enlarged spleen and fluid accumulation in the abdominal cavity. In some people, continued inflammation slowly damages the liver, eventually resulting in severe scarring of the liver, liver failure and sometimes liver cancer.

In addition to common and everyday body aches that many people experience, Hepatitis patients also suffer from the virus's discomforting symptoms, such as headaches, liver pain and joint pain.

Prior to attempting pain management, it is imperative that you discuss your symptoms and available options with your doctor. A knowledgeable physician will be able to give sound advice in regard to which analgesic may be best for you. The manufacturer, as well as a doctor, can provide appropriate dosing recommendations.

Rather then self-treating pain with over-the-counter medications and possibly harming an already overexerted liver, many Hepatitis patients instead turn to non-medication options. Massage therapy, heat packs, topical pain relievers, and gentle stretching are some safe alternatives for pain management. Getting enough sleep is yet another safe way to aid in pain reduction.

Nursing Diagnosis Nursing Care Plan for Hepatitis

Acute Pain related to swelling of the inflamed liver and portal vein dam

Expected results:

Show signs of physical pain and behavior in pain (not to wince in pain, crying intensity and location)

Nursing Interventions Nursing Care Plan for Hepatitis

a. Collaboration with individuals to determine the method can be used to reduce the intensity of pain

R / pain associated with hepatitis very uncomfortable, because stretching the capsule of the liver, through the approach to individuals who experience pain comfort changes are expected to more effectively reduce the pain.

b. Indicate the client's acceptance of the client's response to pain

• Acknowledge the pain
• Listen attentively client's expression of pain

R / clients who have tried to convince health providers that he was experiencing pain

c. Provide accurate information

• Explain the causes of pain
• Indicate how long the pain will end, if known

R / clients are prepared to experience the pain through the explanation of the real pain will tend to be more peaceful than clients who receive an explanation less / not an explanation.

d. Discuss with your doctor the use of analgesics that do not contain hepatotoxic effects

R / likelihood of pain already can not be limited to techniques for reducing pain.

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