koz74686_ch46.

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1226 UNIT X / Promoting Physiologic Health

CONCEPT MAP Acute Pain

LC 6' 3", 200 lb HR = 90

57 y.o. male C/o abdominal pain (7/10) BP = 158/82
Strangulated inguinal Restless Resp = 24
assess Legs drawn up to chest Skin pale, moist
hernia --> partial bowel
obstruction --> second Pupils dilated CXR and UA negative
day postop Midline abd incision with WBC 12,000
sutures dry and intact

generate nursing diagnosis

Acute Pain r/t tissue injury secondary to surgical intervention

outcome outcome

Outcomes partially Pain Control aeb often Pain Level aeb mild Outcomes partially
met: demonstrating ability to: to no: met:
Requests Use analgesics Reported pain Verbalizes pain
analgesic appropriately Protective body and discomfort
evaluation evaluation
30 minutes Use non-analgesic positioning States pain is
before relief measures Restlessness 2/10 30 minutes
ambulation Report uncontrolled Pupil dilation after analgesic
Willing to try symptoms to health Perspiration No protective
relaxation care professional Change in BP, HR, body positioning
techniques but R from normal No pupil dilation
has not done so baseline data
to date

nursing intervention nursing intervention nursing intervention

Analgesic Administration Simple Relaxation Therapy Pain Management

activity activity activity activity activity

activity activity activity

Evaluate Demonstrate and Pain Consider

effectiveness practice relaxation Assessment cultural
of analgesic techniques influences

Determine type Instruct to Check willingness Reduce or

of analgesic request to use relaxation eliminate factors
based on pain analgesic at strategies that increase
assessment onset of pain the pain