ACUTE PAIN

ASSESSMENT
S:
O:
Patient
manifested:
-pain scale of
8/10
- guarding
behavior
- narrowed
focus
- restlessness
- irritability

DIAGNOSIS
Acute pain
related to
presence of
surgical
incision

SCIENTIFIC
EXPLANATION
In performing
parathyroidecto
my, the incision
causes direct
irritation to the
nerve endings
by chemical
mediators
released at the
site such as
bradykinin. This
irritation will
send signal to
the cortex and
thalamus of the
brain thus
producing pain.

PLANNING
Short Term:
After 4 hours of
nursing
interventions,
the patient will
be able to feel
decreased pain
from scale of
8/10 to 5/10

Long Term:
After 2 days of
nursing
interventions,
the patients SO
will verbalize
nonpharmacologic
al methods that
will provide
relief to the
patient.

INTERVENTIONS
Monitor and
record vital
signs
Assess general
condition
Stress proper
hand hygiene
Assess verbal
and non-verbal
reports of pain,
noting location,
intensity and
duration
Place in Semifowlers position
and support
head and neck
with pillows
Maintain head
and neck in
neutral position
and support
during position
changes
Encourage
patient to use
relaxation
techniques

RATIONALE
To obtain
baseline data
To identify
causative
factors
To prevent
infection and
cross
contamination
Useful in
evaluating
pain, choice of
interventions,
effectiveness of
therapy
Prevents
hyperextension
of the neck
and protects
integrity of
suture line
Prevents stress
on the suture
line and
reduces muscle
tension

Helps divert
attention from

EVALUATION
Short Term:
After 4 hours of
nursing
interventions,
the patient
shall have felt
decreased pain
from scale of
8/10 to 5/10.

Long Term:
After 2 days of
nursing
interventions,
the patients
SO shall
haveverbalized
nonpharmacologic
al methods that
will provide
relief to the
patient.

such as
listening to
music or
reading books
Administer and
monitor
medications as
ordered

pain and
discomfort

To determine
effectiveness
and side effects