Page 7 - Pleural Effusion Nursing care plan
P. 7
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Pain Related to the Disease Process
Related To
Injuring agents (e.g., biological—inflammation of lung parenchyma, cellular reactions to circulating
toxins; physical—persistent coughing)
Assessment
• Verbal/coded report [pleuritic chest pain, headache, muscle or joint pain]
• Guarded behavior
• Expressive behavior—restlessness
Goals and outcomes
• Client will verbalize relief or control of pain.
• Client will demonstrate relaxed manner, resting, sleeping, and engaging in activity appropriately.
Nursing Interventions and Rationale
Nursing Interventions Rationale
Assessment
Chest pain, usually present to some degree with
Determine pain characteristics, such as
sharp, constant, and stabbing. pneumonia, may also herald the onset of
complications of pneumonia, such as pericarditis
Investigate changes in character, and endocarditis.
location, and intensity of pain.
Changes in heart rate or blood pressure (BP) may
indicate that client is experiencing pain, especially
Monitor vital signs.
when other reasons for changes in vital signs have
been ruled out.
Interventions
Provide comfort measures, such as back Non analgesic measures administered with a
rubs, change of position, and quiet gentle touch can lessen discomfort and augment
music or conversation. therapeutic effects of analgesics.
Client involvement in pain control measures
Encourage use of relaxation and promotes independence and enhances sense of
breathing exercises.
well-being
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