Cues S > masakit ya ing kening tagiliran ku.

O > with CTT tube inserted at lateral side of right lung clamped, draining at the (+) facial grimace (+) guarding behavior at the insertion site Pain scale of 5/10 Presence of pain when patient is moving

Nursing Diagnosis Acute Pain related to irritation of nerve endings to CTT insertion as evidenced by verbal report and guarding behavior

Scientific Explanation Due to the irritation of nerve endings brought about by the CTT insertion there was pain sensation resulted from conducted action potentials brought about by the stimulation of pain receptors in local areas of the body.

Planning After 4o of nursing interventions, the patient will be able to verbalize adequate relief of pain and patients pain will decrease from 5/10 to 3/10.

Intervention Establish rapport Assess pain characteristics: the quality, severity, location, onset and duration of pain Monitor signs and symptoms associated with pain such as BP, HR, Temperature, color & moisture of skin and ability to focus Assess for probable cause of pain Evaluate the patients response to pain and medications

Rationale to gain trust and cooperation of patient Assessment of pain characteristics is the first step in planning pain management strategies Attention to associated signs and symptoms may help the nurse in evaluating pain Different etiological factors respond better to different therapies Discrepancies between behavior and what the patient says maybe a reflection of other methods the patient is

Evaluation

Assess to what
degree cultural, environment and intrapersonal

factors may contribute to pain or pain relief Evaluate what the pain means to the individual Assess patients willingness to explore a range of techniques aimed at controlling pain Encourage patient to refrain from moving Give patient periods of rest and sleep Encourage patient to verbalize feelings

using to cope with pain relief These variables may modify the patients expression of his or her experience Meaning of pain will directly influence the patients response Some patients will feel ucomfortable doing alternative methods of pain relier To relieve pain Pain may become exaggerated as a result of fatigue Helps in determining appropriate interventions needed and promotes trust and cooperation

Provide comfort measures such as positioning patient in a comfortable position Provide divertional activities like talking to the patient

 Determine
appropriate pain relief method

To lessen feeling of pain Patients feeling of pain will be diverted Unless contraindicated, all patients with acute pain should receive analgesic Analgesics relieve pain

Give analgesic as ordered