EXPLANATION OF GOALS AND
ASSESSMENT NURSING INTERVENTION RATIONALE EVALUATION
THE PROBLEM OBJECTIVES
Gouty arthritis is a LTO Dx FULLY MET IF:
S> “Naut-ut latta disorder of purine >After 3 days of > Assess pain > To rule out worsening of underlying LTO: After 3 days of
met jay sakak lal metabolism nursing characteristics: quality, condition or development of nursing intervention, the
lalo nu magna ak”, characterized by intervention, the severity, location, onset complications. (Doenges, et. Al., Nurse’s patient was able to
as verbalized by elevated uric acid patient will be able and duration of pain, Pocket Guide, 9th Ed. p.500) maintain pain free
the patient. levelswith to maintain pain severity, location, onset condition.
> Rated pain as deposition of urate free condition. and duration of pain.
8/10 in severity, crystals in joints STO; After 30 mins. of
localized at the left and other tissues. > Observe non verbal cues > Observations may or may not be nursing interventions, the
foot, characterized In the case of the STO and pain behaviors. congruent with verbal reports or may be patient was able to
as throbbing, patient, it > After 30 mins. of only indicator present when client is experience relief of pain
continuous by deposited on the nursing unable to verbalize. (Doenges, et. Al., from 8/10 to 2/10 as
timing, non tissues of the left interventions, the Nurse’s Pocket Guide, 9th Ed. p.500) manifested by:
radiating and foot producing pain patient will be able a. absence of facial grimace
aggravated by and swelling. to experience relief Tx b. no abdominal guarding
movement and Pain is an of pain from 8/10 > Provide comfort > To provide non pharmacological pain c. vital signs within normal
alleviated by rest. unpleasant sensory to 2/10 as measures such as use of management. (Doenges, et. Al., Nurse’s range
O experience arising manifested by: incentive spirometry or Pocket Guide, 9th Ed. p.368) d. can demonstrate non
> facial grimace from potential a. absence of facial blow bottles pharmacological ways to
upon palpation tissue damage. It is grimace upon relief pain
> guarding a subjective state in palpation > Provide psychological > If the client is ill, ascertain the e. verbalization of relief
behavior which a person b. no guarding on support or motivation. motivation for returning to an optimal from pain.
> limited, slowed demonstrates the left foot level of wellness. (Medical-Surgical
movement noted discomfort. Pain c. vital signs within Nursing, 7th Ed. By Black and Hawk p. 75) PARTIALLY MET IF:
on the affected interferes with a normal range LTO: After 3 days of
side person’s ability to d. can demonstrate > Administer medications > Necessary for treatment of the nursing intervention, the
> purplish rest, concentrate non analgesics like ketorolac underlying cause. (Nurse’s Pocket Guide, patient was NOT able to
discoloration and and perform pharmacological and mefenamic acid as 9th Ed. By Doenges, et. Al., p.542) Ketorolac maintain pain free
swelling noted normal activities. ways to relief pain prescribed. decreases prostaglandin synthesis by non- condition.
around the left e. verbalization of selective competitive inhibition of cyclo- But
foot relief from pain. oxygenase (COX-1 and COX-2), producing STO; After 30 mins. of
> with limited peripherally-mediated analgesia. nursing interventions, the
answers to (http://www.medscape.com patient was able to
questions /viewarticle/750116_2) experience relief of pain
>sweating noted Mefenamic acid binds the prostaglandin from 8/10 to 4/10 as
on the forehead synthetase receptors COX-1 and COX-2, manifested by:
and the back inhibiting the action of prostaglandin a. absence of facial grimace
synthetase. As these receptors have a role b. no abdominal guarding
as a major mediator of inflammation c. vital signs within normal
A> Acute pain and/or a role for prostanoid signaling in range
related to activity-dependent plasticity, the d. can demonstrate non
inflammatory symptoms of pain are temporarily pharmacological ways to
process secondary reduced. relief pain
to gouty arthritis (http://www.drugbank.ca/ e. verbalization of relief
drugs/DB00784) To maintain acceptable from pain.
level of pain. (Doenges, et. Al., Nurse’s
Pocket Guide, 9th Ed. p.368) NOT MET IF:
There was no improvement
> Assist with laboratory or > To determine changes indicative of at all. (Still with 9/10 pain)
diagnostic studies as healing or infection or complications. To
indicated. identify causative or precipitating factors.
(Doenges, et. Al., Nurse’s Pocket Guide, 9 th
Ed. p.70)
> Assist with ROM > To promote circulation and prevent
exercises. excessive tissue pressure. (Fundamentals
of Nursing 7th Ed by Kozier p. 535)
Edx
> Encouraged to > Unrelieved pain can create other
> Instruct the client to problems such as anxiety, immobility,
report any improvement or respiratory problems and delay in healing.
exacerbation in pain (Medical-Surgical Nursing, 7th Ed. By Black
experience. and Hawk p. 443)
> Encourage verbalization > Only the client can judge the level and
of feelings about the pain. distress of pain; pain management should
be a team approach that includes the
client. Very few people lie about pain.
(Medical-Surgical Nursing, 7th Ed. By Black
and Hawk p. 443)
> Encourage and assist > Deep breathing for relaxation is easy to
client to do deep breathing learn and contributes to pain relief and /
exercises or reduction by reducing muscle tension
and anxiety. (Medical-Surgical Nursing, 7th
Ed. By Black and Hawk p. 479)
> Encourage relatives to > The human body is believed to have
perform touch therapy. energy fields that express aberrant
patterns when body systems are insulted.
Therapeutic touch is thought to realign
aberrant fields. (Medical-Surgical Nursing,
7th Ed. By Black and Hawk p. 480)
> Encourage mobilization. > To promote circulation and prevent
excessive tissue pressure. (Fundamentals
of Nursing 7th Ed by Kozier p. 535)
> Encourage adequate rest > To prevent fatigue. (Doenges, et. Al.,
periods including Nurse’s Pocket Guide, 9th Ed. p.368)
uninterrupted periods of
sufficient duration, meeting
comfort needs, limiting /
avoiding use of caffeine or
alcohol and medications
affecting REM sleep.
> Discuss with the relatives > Promotes early detection of developing
the importance of early complications. (Kozier, Fundamentals of
detection and reporting of Nursing 7th Ed, p. 536)
changes in condition or any
unusual physical
discomforts or changes.
> Teach the client and > It may be possible to teach clients a
significant others about the combination of these techniques to
non pharmacologic ways to maximize their opportunities for self
lessen pain. control over manifestations of pain. (Black
and Hawk, Medical-Surgical Nursing, 7th
Ed., p. 476)
