1. DS: Acute Pain Increased intra- Acute Pain b.d 1.Pain control 1. Pain Management
ocular pressure Increased TIO Indicators : Activities :
Clients said visual
(TIO) The patient can Problem a comprehensive
acuity reduced
perform deep assessment of pain to
The client says and
breathing include location,
see the colors of the
exercises characteristic,
rainbow glare around
independently onset/duration, frequency,
lights
After being quality, intencity of
Clients say headache
trained in the anxiety of pain and
and around the eyes ,
techniques of precipitating factors
and sometimes
breath 3 times in Observe for nonverbal
nausea .
24 hours for 3 cues of discomfort,
days reduced pain aspecilly in those unable
DO : expected from a to communicate
scale of 6 to 3 effectively
vital signs :
after being given Explore pain knowledge
• TD : 150/100 mmHg
analgesics 3 days and beliefs about pain
• Nadi : 80x / min
from the first day
• Temperature : 37 ° C
• Breathing : 20x / min . to come to the Determine the impact of
• Scale pain : 8 clinic are expected the pain experiences on
to decrease quality of life
patient's pain Provide information about
the pain, such as cause of
2.Pain Level the pain, how long it will
Indicators : last, and anticipate
Patients are discomforts from
expected to procedures
describe the level Control environmental
of pain using a factors that may influence
pain scale the patients response to
Patients are discomfort (e.g,room
expected to be temperature lighting
able to control noise)
anxiety to pain Reduce or eliminate
focus patients are factors that recipitate or
expected not to increase the pain
get sidetracked experience (e.g, fear
by the pain fatigue monitori and lack
knowledge)
Select and implement a
variety of measures (e.g,
pharmacological non
pharmacological
interpersonal ) to facilitate
pain relief, as appropriate
Consider type and source
of pain when selecting
pain relief strategi
Teach the use of
pharmacological
techniques
Collaborate with the
patient, significant order ,
and other health
professional to select and
implement non
pharmacological pain
relief measure
2.Analgesic Administration
Activities :
Determine pain location,
characteristics, quality,
and severity before
medicating patient
Check a medical order for
drug, dose, and frequency
of analgesic prescribed
Check history for drug
allergies
Evaluate the patient’s
ability to participate ini
selection of analgesic,
route, and dose, and
involve the patient, as
appropriate
Choose the appropriate
analgesic or combination
of analgesics when more
than one is prescribed
Determine analgesic
selection (narcotic, non
narcotic, or NSAID)
based on type and severity
of pain
Determine the preferred
analgesic, route of
administration, and
dosage to achieve optimal
analgesia
Monitar vital sign before
and after administering
narcotic analgesic with
first time dose or if
unusual sign are noted
Attend to comfort needs
and other activities that
assist relax action to
facilitate to analgesia
Document response to
analgesic and any
untoweard effect