Problem: Acute Pain

Nursing Diagnosis: Acute pain related to incision secondary to insertion of chest thoracostomy tube.
Taxonomy: Cognitive-Perceptual Pattern
Cause Analysis: Pain after a thoracotomy may be severe depending on the type of incision and the patient!s reaction to and ability to cope the pain. Deep inspiration is very painful after
thoracotomy. Pain can lead to breathe deeply and cough and if it further limits chest excursions so that ventilation becomes ineffective.
Cues "b#ectives $nterventions %ationale &valuation
'ub#ective:
( sa)it a)ong )ilidi sige ug
ngutngot* as verbali+ed by
patient. ,sacle of ---. level of / is
the pain 0
"b#ective:
distraction behaviors e.g.
restless as noted
guarding affected area as
noted
irritable
scale of ---. pain felt at
/ bearable
guarding of the area as
noted
presence of dressing and
binder as noted

'hort Term:
After eight hours of nursing
interventions patient 1ill report
pain relieved2controlled scale of 3
out of -..
4ong Term:
After three days of nursing
intervention patient 1ill appear
relaxed and can participate in
desired2needed activities such as
1al)ing out from bed.
$ndependent:
Asses pain reports
noting location fre5uency
and intensity in scale --
-.. Note nonverbal cues
e.g. restless.
&xplore 1ith the client
possible factors that
precipitate or intensify the
pain experience
,e.g. activity
movement 0
Assist 1ith self-care
activities and ambulation.
Provide diversional
activity such as listening
to music 1atching T6
and reading.
&ncourage patient to
$ndicates need for
effectiveness of
interventions and may
signal
development2resolution of
complications.
$dentifying actual or
potential precipitating
factors helps the client
avoid or minimi+e them.
Prevents undue fatigue
and incision strain.
&ncouragement and
physical assistance2
support may be needed
for some time before
patient is able or
confident enough to
perform these activities
because of pain and
fear of pain.
This 1ill divert the client!s
attention not to often thin)
of the pain she2he suffer.
%educes the feeling of
pain and anxiety.

verbali+e her feeling
Assess incision area
every 7 hours for
redness heat induration
s1elling separation and
drainage.
Dependent
Assist 1ith patient-
controlled analgesia
,PCA0 or analgesia
through epidural catheter.
Administer intermittent
analgesics routinely as
indicated.
These signs indicate
possible infection.
8aintaining a constant
drug level avoids cyclic
periods of pain aids in
muscle healing and
improved emotional and
physical
discomfort2coping.
%eferences:
Nursing Care Plans 8edical-'urgical Nursing
9uidelines for $ndividuali+ing Patient Care 6olume - -.
th
&dition
Page -7/--7: ;y: 'u+anne 'melt+er < ;renda ;are
&dition / pp: /33 < /3=
;y: 8ary >rances 8oorhouse 8arilynn &. Doenges Alice C. 9eissler- 8urr