Dat

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

After the whole

nursing
intervention, the
patient will:

1.) Monitor vital signs.

1.) Verbalize and

demonstrate
(nonverbal cues)
relief and/or
control of pain or
discomfort.

2.) Assess for signs and

symptoms associated with
chronic pain such as
fatigue, decreased appetite,
weight loss, changes in
body posture, sleep pattern
disturbance, anxiety,
irritability, restlessness, or
depression. Patients with
chronic pain may not exhibit
the physiological changes
and behaviors associated
with acute pain.

P
A
T
T
E

2.) Gain
knowledge on
how to deal with
the pain.

Nursing Intervention

Increased pain will

improve vital signs.

Patient with chronic pain

may not exhibit the
physiological changes and
behaviors associated with
acute pain.
3.) Assist in thorough
diagnosis. Including

Evaluation

After the whole

nursing
intervention, the
patient was able to
control pain or
discomfort and was
able to gain
knowledge on how
to deal with the
pain being felt.

Pain will always

be present with
the patient since
he has a chronic
illness. Thus
health teachings
were given to the
patient to help
with the pain.

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

physical, neurological and

psychological evaluation.
The pathophysiology of
chronic pain is multifactorial.
Some believe that response
to it is a learned behavioral
syndrome that begins with a
noxious internally or
externally.
4.) Observe and record the
location of the severity of
complaints (scale 0-10) and
the effects of pain.
Helps to distinguish the
cause of pain and provide
information about the
progress or improvement of
disease, complications, and
effectiveness of
interventions.
5.) Evaluate emotional
components of individual
situation.
Many painful conditions
cause or exacerbate
emotional responses (e.g.,
major depression,

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

emotions and enhance

coping mechanism.
12.) Provide quite
environment, calm activities
and adequate rest reinforce.
To prevent fatigue and
lessen stimuli.
13.) Provide comfort
measures such as back rub,
change position, use of
heat/cold.
To provide nonpharmacologic pain
management.
14.) Instruct/encourage use
of relaxation exercise such
as focused breathing.
This is a form of
relaxation technique that
helps level of pain.