CUES

SUBJECTIVE:
- Patient
verbalized
Masakit
yung tuhod
ko, yung
parte na
may
nakatusok,
- Verbalized
Namaman
hid yung
tuhod ko,
parang may
tumutusok,
pasumpong
-sumpong
sya.
- Verbalized
Mas
masakit
yung
rayuma ko
sa kaliwang
kamay,
pasumpong
-sumpong
sya.
- Verbalized
Masakit

NURSING INFERENCES
DIAGNOSIS
Acute pain
related
to
physical
agent
and
inflammatory
process
secondary to
insertion of
Steinmann
pin
and
presence of
arthritis
respectively

Unrelieved
acute pain leads
to debilitation,
diminished
quality of life,
and depression.
Unrelieved
acute
postoperative
pain leads to
development of
chronic pain
syndromes and
increased
complications.
In fact,
unrelieved pain
can kill.

PLANNING

NURSING
INTERVENTIONS

GOAL:
After 8 hours of
nursing
interventions, the
patient will be
able to experience
gradual
reduction/relief of
pain.

INDEPENDENT:
1. Instruct client to
report any
improvement/exac
er-bation in pain
experience.

OBJECTIVES:
After the series of
nursing
interventions, the
patient will be
able to:
2.
1.

verbalize
reduction/
relief of pain.

Source:
MedicalSurgical
2. have normal
th
Nursing, 7 ed.
Respiratory
by Black, Joyce
Rate.
M. and Jane
Hokanson
3. move his left
Hawks; p. 440
upper
extremity
without facial
grimace

Encourage
verbalization of
feelings about the
pain.

RATIONALE

EVALUATION

INDEPENDENT:
1. Unrelieved pain
can create other
problems such as
anger, anxiety,
immobility,
respiratory
problems, and
delay in healing.
(Medical-Surgical
Nursing, 7th ed. by
Black, Joyce M.
and Jane
Hokanson Hawks;
p. 443)

EFFECTIVENESS:
Was the patient able to
experience gradual
reduction/relief of pain
after 8 hours of nursing
interventions?
__yes
__no
why?

2.

Was the patient able to

have normal respiratory
rate after the series of
nursing interventions??
__yes
__no
why?

Only the client can

judge the level and
distress of pain;
pain management
should be a team
approach that
includes the client.
Very few people
lie about pain.
(Medical-Surgical
Nursing, 7th ed. by
Black, Joyce M.
and Jane
Hokanson Hawks;

Was the patient able to

verbalize reduction/relief
of pain after the series of
nursing interventions?
__yes
__no
why?

Was the patient able to

move his left upper
extremity without facial
grimace after the series
of nursing interventions?
__yes
__no
why?

yung
rayuma ko
lalo na pag
ginagalaw
ko; lagi
syang
kumikirot.
OBJECTIVE:
- Pain scale
of 10 for
arthritis on
left wrist
- Pain scale
of 2 for site
of
Steinmann
pin
insertion
- RR: 21
cpm
- Exhibited
facial
grimace
upon
movement
of the left
upper
extremity
- Exhibited
facial
grimace
upon

Etiology of
4. have no facial
Acute Pain
grimace upon
from the Site of
palpation of
Steinmann Pin
the wrist
Insertion:
Immediate
cause:
Activation of
nociceptors or
pain receptors

5.

6.
Intermediate
cause:
Break in the
skin integrity

p. 443)
3.

recite the
nonpharmacol
ogic ways to
lessen pain.
demonstrate
the
nonpharmacol
ogic ways to
lessen pain.

Provide comfort
3. To provide
measures such as
nonpharmacologic
use of incentive
pain management.
spirometry or blow
(Nurses Pocket
bottles.
Guide, 9th ed. by
Doenges,
Marilynn, et.al., p.
368)

4.

Encourage
relatives to
perform touch
therapy.

5.

Encourage and
assist client to do
deep breathing
exercises.

Root cause:
Insertion of
Steinmann pin
Etiology of
Pain on Left
Wrist:
Immediate
cause:
Activation of
nociceptors or
pain receptors
Intermediate
cause:

Was the patient able to

have no facial grimace
upon palpation of the
wrist after the series of
nursing interventions?
__yes
__no
why?

Was the patient able to

recite the
4. The human body
nonpharmacologic ways
is believed to have to lessen pain after the
energy fields that
series of nursing
express aberrant
interventions?
patterns when body
__yes
__no
systems are
why?
insulted.
Therapeutic Touch Was the patient able to
is thought to
demonstrate the
realign aberrant
nonpharmacologic ways
fields. (Medicalto lessen pain after the
Surgical Nursing,
series of nursing
th
7 ed. by Black,
interventions?
Joyce M. and Jane
__yes
__no
Hokanson Hawks;
why?
p. 480)
EFFICIENCY:
5. Deep breathing for Were the human
relaxation is easy
resources, materials and
to learn and
time used economically?
contributes to pain __yes
__no
relief and/or
why?

palpation
of the wrist

Inflammatory
process
Root cause:
Presence of an
underlying
disease/
condition
(Rheumatoid
and Gouty
arthritis)

reduction by
reducing muscle
tension and
anxiety. (MedicalSurgical Nursing,
7th ed. by Black,
Joyce M. and Jane
Hokanson Hawks;
p. 479)
6. Provide
6. If the client is ill,
psychological
ascertain the
support/motivation
motivation for
.
returning to an
optimal level of
wellness. (MedicalSurgical Nursing,
7th ed. by Black,
Joyce M. and Jane
Hokanson Hawks;
p. 75)

7. Encourage
mobilization of the
left upper
extremity. Assist
with ROM
exercises.

8. Encourage
adequate periods

7. To promote
circulation and
prevent excessive
tissue pressure.
(Fundamentals of
Nursing 7th ed. by
Kozier, Barbara, p.
535)
8. To prevent fatigue.
(Nurses Pocket
Guide, 9th ed. by

APPROPRIATENESS:
Were the interventions
suitable to clients
situation?
__yes
__no
why?
Were the setting and
time table interventions
realistic to clients
situation?
__yes
__no
why?
ACCEPTABILITY:
Were the interventions
accepted by the patient
(without any signs of
rejection from the patient
and family members)?
__yes
__no
why?
ADEQUACY:
Was the number of
interventions sufficient
to meet the desired goal
and objectives?
__yes
__no
why?

of rest and sleep,

including
uninterrupted
periods of
sufficient duration,
meeting comfort
needs, limiting/
avoiding use of
caffeine/ alcohol
and medications
affecting REM
sleep. Encourage
quiet, restful
atmosphere.
9. Discuss with
relatives the
importance of
early detection and
reporting of
changes in
condition or any
unusual physical
discomforts/
changes.
10. Teach the client
and significant
others about the
nonpharmacologic
ways to lessen
pain.

Doenges,
Marilynn, et.al., p.
369)

9. Promotes early
detection of
developing
complications.
(Fundamentals of
Nursing 7th ed. by
Kozier, Barbara, p.
536)

10. It may be possible

to teach clients a
combination of
these techniques to
maximize their
opportunities for
self-control over
manifestations of

pain. (MedicalSurgical Nursing,

7th ed. by Black,
Joyce M. and Jane
Hokanson Hawks;
p. 476)
11. To meet pain
control goal.
11. Notify physician if
(Nurses Pocket
regimen is
Guide, 9th ed. by
inadequate.
Doenges,
Marilynn, et.al., p.
368)
COLLABORATIVE:
1. Necessary for
treatment of the
COLLABORATIVE:
1. Administer
underlying cause.
medications
(Nurses Pocket
(particularly
Guide, 9th ed. by
analgesics) as
Doenges,
prescribed.
Marilynn, et.al., p.
542)
To maintain
acceptable level of
pain. (Nurses
Pocket Guide, 9th ed.
by Doenges,
Marilynn, et.al., p.
368)
2. To determine
changes indicative

2.

Assist with
laboratory/diagnos
tic studies as
indicated. (e.g.,
Chest Ultrasound).

of healing/
infection/
complications. To
identify
causative/precipitating factors.
(Nurses Pocket
Guide, 9th ed. by
Doenges,
Marilynn, et.al., p.
70)

XI. NURSING CARE

PLANS