Page 13 - PNEUMONIA NURSING CARE PLAN

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ACUTE PAIN

Increased sputum production in pneumonia comes with frequent coughing. Persistent coughing can
be painful therefore the need for Acute Pain nursing diagnosis.

Related Factors
• Inflammation of lung parenchyma
• Cellular reactions to circulating toxins
• Persistent coughing

Assessment
• Reports of discomfort: pleuritic chest pain, headache, muscle/joint pain
• Guarding of affected area
• Self-focused
• Moaning, restlessness
• Facial mask, distraction behaviors
• Irritability
• Tachycardia
• Increased BP
• Tachypnea

Goals and expected outcomes
• Patient will verbalize relief/control of pain at level less than 3 to 4 using a rating scale of 0 to 10.
• Patient will demonstrate relaxed manner, resting/sleeping and engaging in activity appropriately.
• Patient will verbalize understanding of nonpharmacological interventions for pain relief.

Nursing Interventions and Rationales
These nursing interventions and actions are for pain relief to facilitate effective mobilization of
secretions through coughing and deep breathing exercises.

Nursing Interventions Rationale

Assessment

Assess pain characteristics: sharp, constant, Chest pain, usually present to some degree with
stabbing. Investigate changes in character, pneumonia, may also herald the onset of
location, or intensity of pain. Assess reports of complications of pneumonia, such as
pain with breathing or coughing. pericarditis and endocarditis.

Changes in heart rate or BP may indicate that
patient is experiencing pain, especially when
Monitor vital signs.
other reasons for changes in vital signs have
been ruled out.

Therapeutic Interventions

Provide comfort measures: back rubs, Non-analgesic measures administered with a
position changes, quite music, massage. gentle touch can lessen discomfort and

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