Nursing
Nursing Diagnosis
Problem with
With Rationale
Objectives
Nursing Interventions
Rationale for
Evaluation
Interventions
cues Problem Pain
Acute Pain related to
After 1 hour of
inflammatory process
nursing
Subjective
and destruction of
intervention,
cues: “I cues: “I feel
the joint.
client will be
may joints are very painful every time I wake up in the morning”, as verbalized by the client.
Pain Scale: 8/10
Rationale: Joint pain is due to prostaglandin release, edema, and synovial inflammation and destruction.
able to verbalize pain is relieved from 8/10 to
Assessment: a. Investigate a. Investigate reports of pain, location, intensity. Note precipitating factors and nonverbal cues. (Pain scale: 8/10, scale: 8/10,
Characteristic: Aching
teaching client will be able to: Identify 5 pain management
Objective cues: guarding or protective behavior, facial grimacing
hour of nursing
and effectiveness of the
intervention,
program. b. Duration b. Duration of the pain disease.
and maintains neutral position. Use of splints
Location: joints Location: joints on both sides of the body
can decrease pain and may reduce damage to
techniques such as biofeedback,
met. After an
pain management needs
a2. Rests a2. Rests painful joints Onset: Every Onset: Every mornings
b. Duration: 2-3 Duration: 2-3 hours
the joint.
guided-imagery, controlled breathing,
visualization. Perform through
Exacerbation: movements, or stress on joints
was controlled with pain scale of 5/10. After 3 hours of health teaching, client was able to identify 5 out of 5 pain
Radiation: non-radiating
Associated s/s: tenderness, s/s: tenderness, swelling, warmth, stiffening
management
to perform 3 out of 5 pain
relaxation and mobility,
management
decreases pain, and
techniques.
d2. Prevents d2. Prevents fatigue and joint stiffness. stiffness. Stabilizes Stabilizes
Independent:
joint, decreasing decreasing joint joint movement and associated
a2. Place a2. Place pillows, sandbags, trochanter rolls,
Client was able
c2. Heat c2. Heat promotes muscle
relieves morning stiffness.
the 5 pain
techniques.
and reduces muscle
Relief: Warm Relief: Warm compresses on joints
demonstration
lifetime use.
b2. Promotes b2. Promotes relaxation tension.
return
techniques for
client verbalized pain
management
progressive relaxation, and
Goal partially
important in determining
reflects the severity of the
2/10.After 2 hours of health
a. Pain a. Pain assessment is
pain.
and splints.
e2. Promotes e2. Promotes relaxation, reduces muscle tension,
b2. b2. Provide gentle massage.
facilitating participation in therapy.
c2. c2. Apply warm, moist compresses to affected joints several times a day.
1. This 1. This medication inhibits the enzyme COX-2. This enzyme is required for the
d2. Encourage d2. Encourage frequent changes of position. Assist client to move in bed, supporting affected joints above and below.
synthesis of prostaglandins, but is less harmful to the stomach and the kidneys. May take
e2. Medicate e2. Medicate before planned activities. activities.
celecoxib with or without food intake.
Collaborative: 2. This 2. This medication is Administer medications as indicated.
classified under Disease Modifying Antirheumatic Drug (DMARD). DMARD
Example medications:
blocks the destructive effects of interleukin-1 on
1. celecoxib 1. celecoxib (Celebrex®) 100 mg/cap, 1 cap
cartilage and bone
BID, PO
resorption by inhibiting its binding at specific tissue
2. anakinra 2. anakinra (Kineret®) 100 mg/ml, 100 mg
at the receptor sites.
OD via Sub a3. Soft a3. Soft or sagging
Health Teaching:
mattress prevents maintenance of proper body alignment, placing
a3. Recommend a3. Recommend firm mattress or bed board.
stress to affected joints.
Elevate linens with bed cradle as needed. b3. Heat b3. Heat promotes muscle b3. Recommend b3. Recommend client to take warm bath or shower on arising or at bedtime.
relaxation and mobility, decreases pain, and
c3. Teach c3. Teach client the different kinds
relieves morning stiffness.
diversional activities or pain management techniques and how to perform them.
c3. Refocuses c3. Refocuses attention, provides stimulation, and
d3. d3. (Biofeedback, guided-imagery,
enhances self-esteem and
controlled breathing, progressive relaxation,
feelings of general well-
and visualization)
being.
Instruct client to follow pharmacologic
d3. Teaching d3. Teaching and
regimen as prescribed. Instruct them the
involving them with their
uses, dosage, time of use, contraindications,
medical regimen increases
interactions, and other medication medication related
their understanding understanding
concerns.
regarding the prescribed medications, thus increasing their pharmacological regimen compliance.
