CUES S: Masakit ang dibdib ko tuwing umuubo ako, parang As the patient verbalized.

. O: The patient appears weak, restless, facial grimace noted and uses guarding behavior of her chest when coughing. VS: T: 37.2, P: 88, R: 29, BP: 130/ 90.

NURSING DIAGNOSIS Acute Pain related to persistent coughing as evidenced by pleuritic chest pain, facial grimace and use of guarding behavior when coughing

RATIONALE Acute pain is described as an unpleasant sensory or emotional experience associated with actual or potential tissue damage or injury a lasting from 6 seconds to 6 months. In cases of fracture, pain is continuous and increasing in severity but will subside significantly on the 5th to 7th day. Pain may be attributed to the increase of pressure caused by the increase production of exudates thus causing pain radiating over the site.

PLANNING After 3 days of nursing intervention, the patient will be able to verbalize and demonstrate decrease in pain from 8/10 to 5/10. After 5 hours of nursing intervention, the patient will be able to: a. demonstrate use of relaxation skills and diversional activities b. follow prescribed pharmacological regimen. c. display relaxed manner.

INTERVENTION INDEPENDENT 1. Assessment of pain to include location, characteristics, onset/duration, frequency, quality, severity and precipitating and aggravating factors. 2. Assessment of physical signs of pain: increased HR, RR, and BP, restlessness; facial grimace and guarding. 3. Encourage patient to verbalize feelings about the pain. 4. Instruct and assist patient in chest splinting techniques during cough episodes. 5. Offer frequent

RATIONALE Enables the nurse to assess the subjective experience of pain of the patient

EVALUATION After 3 days of nursing intervention, the patient was able to verbalize and demonstrate decrease in pain from 8/10 to 5/10. After 5 hours of nursing intervention, the patient was able to: a. demonstrate use of relaxation skills and diversional activities b. follow prescribed pharmacologica l regimen. c. display relaxed manner.

Objective data may be a more reliable indicator of pain in certain clients. Some clients are reluctant to admit the extent of pain or to request pain medication. Helps to alleviate anxiety.

Aids in control of chest discomfort while enhancing effectiveness of cough effort. Mouth breathing and oxygen therapy can irritate and dry

oral hygeine

out mucous membranes, potentiating general discomfort Refocuses attention, promotes sense of control, and may enhance coping abilities in the management of pain, which is likely to persist for an extended period.

6. Encourage use of stress management techniques, e.g, progressive relaxation, deep breathing exercises, visualization/ guided imagery, therapeutic touch. 7. Identify diversional activities appropriate for patient age, physical abilities and personal preferences. DEPENDENT 1. Administer analgesics and antitussives as ordered by the doctor.

Prevents boredom, reduces tension, can increase muscle strength; may enhance selfesteem and coping abilities

These may be used to suppress non productive/paroxy smal cough or reduce excess mucous, enhancing general

comfort/rest.