e
and
Tim
e
July
29,
201
6/
8:00
pm /
3-11
shift
Cues
Nursing
Diagnosis
Subjective:
Chronic pain
Sakit jud
akong mga tiil,
pero mas
labaw ang
kasakit aning
sa tuo.
Rationale:
Pain is a highly
subjective state
in which a variety
of unpleasant
sensations and a
wide range of
distressing
factors may be
experienced by
the sufferer. Pain
may be a
symptom of
injury or illness.
In multiple
chlerosis, the
sensitized T cells
remain in the
CNS and
promote the
infiltration of
other agents that
damage the
immune system.
Objective:
- Facial
grimace
- Slow
moveme
nt
- Irritable
- Pain
scale:
6/10
Ne
ed
s
Goal of Care
C
O
G
N
I
T
I
V
E
P
E
R
C
E
P
T
U
A
L
P
A
T
T
E
2.) Gain
knowledge on
how to deal with
the pain.
Nursing Intervention
Evaluation
The immune
system attack
leads to
inflammation that
destroys myelin
(which normally
insulates the
axon and speeds
the conduction
of impulses
along the axon)
and
oligodendroglial
cells that
produce myelin
in the CNS that
causes pain to
the patient
experiencing
multiple
sclerosis.
Reference:
Brunner and
Suddarths
Textbook of
Medical-Surgical
R
N
somatization disorder,
hypochondriasis) may be
prone to develop chronic
pain syndrome.
6.) Determine cultural
factors for the individual
situation,
Pain is perceived and
expressed in different ways
(e.g., moaning aloud or
enduring in stoic silence);
some may magnify
symptoms to convince
others of reality of pain.
7.) Perform a
comprehensive assessment
of pain (location, onset,
characteristics, frequency)
To be able to compare
changes from previous
reports to rule out
worsening of underlying
condition/developing
complications.
8.) Determine possible
pathophysiology and causes
of pain.
To know underlying
condition that leads to pain
and possible management
that would not further
aggravate pain.
9.) Perform pain
assessment each time pan
occurs, note and investigate
changes from previous
report.
R: To rule out worsening of
underlying
condition/development of
complication.
10.) Observe nonverbal
cues including how client
walks, holds body, sits,
facial expressions, cool
fingertips/toes, which can
mean constricted vessels.
Observation may or may
not be congruent with verbal
reports indicating need for
further evaluation.
11.) Encourage verbalization
of pain/feelings about the
pain.
To allow out let for