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Student Name: IWALOYE OLUSEYI.O

date: 10/11/2020

Client’s Medical Diagnosis: ACUTE PAIN DUE TO PAINS IN THE JOINTS

STUDENT

INSTRUCTIONS:

In the space below, enter the subjective and objective data gathered during your client assessment.

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Subjective Data Entry

Pain 5/10 in her joints. States that’s she hurts so much.

She cannot move from her bed to the chair.

Patient is moaning and crying.

“Patient states that the pain is severe”

Objective Data Entry

Vital signs:

BP 128/82

PULSE 78, apical

Respirations 16

Temperature 97.3

Need assistance with personal care, needs help to be moved from the bed to the wheelchair. contusion of scalp.

TIME OUT!

Student Instructions: To be sure your client diagnostic statement written below is accurate you need to review the defining characteristics and related factors associated with the nursing diagnosis and see how your client data match. Do you have an accurate match or are additional data required, or does another nursing diagnosis need to be investigated?

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CLIENT DIAGNOSTIC STATEMENT:

Nursing Diagnosis (per NANDA): Acute pain related to physical mobility, bone deformities, and joint degeneration as evidenced by reports of pain/discomfort, fatigue.

Definition of NANDA Dx: Un pleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (international Association for the study of pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end, and with a duration of less than 3 months.

Defining Characteristics of NANDA Dx:

Patient reports pain, guarding behavior, protecting body part, facial mask of pain.

Reference: Denise Sullivan, MSN, ANP-BC and Maureen f. Cooney, DPN, FNP-BC

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Related to Acute pain related to physical mobility, bone deformities, and joint degeneration.____________________________________________________________________________________________________

As Evidenced By Reports of pain/discomfort, guarding body part and facial mask of pain._______________________________________________________________________________________________________________

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TIME OUT!

The desired outcome must meet criteria to be accurate. The outcome must be specific, realistic, measurable, and include a time frame fcompletion. Does the action verb describe the client’s behavior to be evaluated? Can the outcome be used in the evaluation step of the nursing process to measure the client’s response to the nursing interventions listed below?

Short-Term Goal #1: Patient will report relieved/controlled pain on a scale of less than 2 in 24hours.

Interventions for Goal 1:

Rationales for Interventions:

1. Consider reports of pain, noting location and intensity (scale of 0-10). Note precipitation factors and non-verbal pain cue.

Favorable in determining pain management needs and effectiveness of the program.

Patient may report pain in the fingers, hips, knees, lower lumber spine, and cervical vertebrae. Pain is usually provoked by activity and relieved by rest; joint pain and aching may also be present when the patient is at rest.

Pain may manifest as an ache, progressing to sharp pain when the affected area is brought to full weight-bearing or a full range of motion (ROM). The patient may experience sharp, painful muscle spasms and paresthesias.

Reference: Ackley, B.J., Ladwig, G.B., Msn, R.N., Makic, M.B.F., Martinez-Kratz, M., & Zanotti, M. (2019). Nursing Diagnosis Handbook E-Book: An Evidence-Based Guide to planning care. Mosby

2. Recommend or provide a firm mattress or bed-board, small pillow. Elevate linens with bed cradle as needed.

Soft and sagging mattress, large pillows prevent maintenance of proper body alignment, placing stress on affected joints. Elevation of bed linens reduces pressure on inflamed or painful joints.

Flexion of the joints may reduce muscle spasms and other discomforts.

Decreases pressure on fragile tissues to reduce risks of immobility and development of decubitus.

Reference: Ackley, B.J., Ladwig, G.B., Msn, R.N., Makic, M.B.F., Martinez-Kratz, M., & Zanotti, M. (2019). Nursing Diagnosis Handbook E-Book: An Evidence-Based Guide to planning care. Mosby

3.suggest patient assume a position of comfort while in bed or sitting in a chair. Promote bed rest as indicated. Place and monitor use of pillows, sandbags, trochanter rolls, splints, braces. Use adaptive equipment (such as cane, walker) as indicated.

In severe disease or acute exacerbation, total bedrest may be necessary (until objective and subjective improvements are noted) to limit pain or injury to joint.

These aids assist in ambulation and reduce joint stress.

Relieves pressure on tissues and promotes circulation. Facilitates self care and patient’s independence. Proper transfer techniques prevent shearing abrasions of the skin.

Rests painful joints and maintains a neutral position.

Note: use of splints can decrease pain and may reduce damage to the joint; however, prolonged inactivity can result in loss of joint mobility and function.

Promotes joint stability (reducing risk of injury) and maintains proper joint position and body alignment, minimizing contractures.

Reference: Ackley, B.J., Ladwig, G.B., Msn, R.N., Makic, M.B.F., Martinez-Kratz, M., & Zanotti, M. (2019). Nursing Diagnosis Handbook E-Book: An Evidence-Based Guide to planning care. Mosby

Short-Term Goal #2: In 2 days, patient will appear relaxed, able to sleep/rest and participate in activities appropriately.

Interventions for Goal 2:

Rationales for Interventions:

1. Encourage frequent changes of position every 2 to 4 four hours. Assist the patient to move in bed, supporting affected joints above and below, avoiding jerky movements.

Prevents general fatigue and joint stiffness. Stabilizes joint, decreasing joint movement and associated pain.

Muscle spasms may result from poor body alignment, resulting in increased discomfort.

Reference: Ackley, B.J., Ladwig, G.B., Msn, R.N., Makic, M.B.F., Martinez-Kratz, M., & Zanotti, M. (2019). Nursing Diagnosis Handbook E-Book: An Evidence-Based Guide to planning care. Mosby

2. Monitor the duration, not the intensity, of morning stiffness.

Duration more accurately reflects the disease’s severity.

The patient may find coping with a progressive, debilitating disease difficult.

Reference: Ackley, B.J., Ladwig, G.B., Msn, R.N., Makic, M.B.F., Martinez-Kratz, M., & Zanotti, M. (2019). Nursing Diagnosis Handbook E-Book: An Evidence-Based Guide to planning care. Mosby

3. Provide gentle massage.

Promotes relaxation and reduces muscle tension.

Reference: Ackley, B.J., Ladwig, G.B., Msn, R.N., Makic, M.B.F., Martinez-Kratz, M., & Zanotti, M. (2019). Nursing Diagnosis Handbook E-Book: An Evidence-Based Guide to planning care. Mosby

Long-Term Goal #1: on a daily basis, patient will incorporate relaxation skills and diversional activities into the pain control program.

Interventions for Long-Term Goal 1:

Rationales for Interventions:

1. Encourage the use of stress management technique such as progressive relaxation and feedback, visualization, guided imagery, self-hypnosis, and controlled breathing. Provide Therapeutic Touch.

Promotes relaxation, provides a sense of control and may enhance coping abilities.

Reference: Ackley, B.J., Ladwig, G.B., Msn, R.N., Makic, M.B.F., Martinez-Kratz, M., & Zanotti, M. (2019). Nursing Diagnosis Handbook E-Book: An Evidence-Based Guide to planning care. Mosby

2. Involve in diversional activities appropriate for individual situation.

Refocuses attention, provides stimulation and enhance self-esteem and feelings of general well-being.

Reference: Ackley, B.J., Ladwig, G.B., Msn, R.N., Makic, M.B.F., Martinez-Kratz, M., & Zanotti, M. (2019). Nursing Diagnosis Handbook E-Book: An Evidence-Based Guide to planning care. Mosby

3. Medicate before planned activities and exercises as indicated.

Promotes relaxation, reduces muscle tension and muscle spasms, facilitating participation in therapy.

Exercise is necessary to maintain joint mobility, but patients may be reluctant to participate in exercise if they are in too much pain.

Reference: Ackley, B.J., Ladwig, G.B., Msn, R.N., Makic, M.B.F., Martinez-Kratz, M., & Zanotti, M. (2019). Nursing Diagnosis Handbook E-Book: An Evidence-Based Guide to planning care. Mosby

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Do your interventions assist in achieving the desired outcome? Do your interventions address further monitoring of the client’s response to your interventions and to the achievement of the desired outcome? Are qualifiers: when, how, amount, time, and frequency used? Is the focus of the action’s verb on the nurse’s actions and not on the client? Do your rationales provide sufficient reason and directions?

What was your client’s response to the interventions?

The patient responded appropriately to the interventions.

Was the desired outcome achieved? If no, what revisions to either the desired outcome or interventions would you make?

Goal 1: Met

Give supporting data: Patient described satisfactory pain control at a level less than 1 to 2 on a rating scale of 0/10 pain 8hours after she was placed on a firm mattress.

Goal 2: Met

Give supporting data: Changing of position helped the patient stabilizes joint, decreasing joint movement and associated pain.

Goal 3: Met

Give supporting data: Patient displays improved well-being such as baseline levels for pulse, BP, respirations, and relaxed muscle tone/body posture.

If any of your goals were “Not Met” or “Partially Met” explain why:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

In your opinion, how could your plan of care be revised or improved to help the patient achieve a better outcome?

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Documentation Focus: Now that you have completed the evaluation, the next step is to document your care and the client’s response. Document all of your interventions, including the time and date that the intervention was performed, in your nurse notes. Be sure to include your patient’s response to the intervention.

Reassessment Data:

Pain 0 out 10

Relaxation and mobility

Relieve morning stiffness