Farah Donna Maulidiane

201611012

English III

Ms. Jones (17 y.o.) has been hospitalized since yesterday with stomach-ache in lower right
abdomen, pain scale 3, she complains of nauseous.

Diagnosis : Acute Pain

Intervention : Pain Management

IMPLEMENTATION STRATEGY

NURSING ACTIONS OF CLIENTS WITH ACUTE PAIN

A. Nursing process

1. Client's condition

Subjective data

a. Clients complains of nauseous

b. Clients complains pain scale 3

Objective data

a. Client looks grimacing in pain holding his stomach

2. Diagnosis : Acute Pain

3. The purpose of nursing : Reduce pain

4. Intervention : Pain management (Breathing relaxation techniques)

B. Communication strategy

1. Orientation Phase

"Hello good morning"

"Let me introduce my self, my name is Farah Donna Maulidiane, you can call me nurse Farah.
I'm nurse on duty today 7 a.m to 2 p.m."

"What is your name miss? And your birth date?"

"How are you feeling today miss?"

"You're feeling stomach ache?"

Contract :

"I will check your condition now, about 10 minutes and you just sit on the bed, the purpose is to
know your condition and to report to the doctor."

"Do you agree miss?"

2. Working Phase

" What do you think the cause of your pain?"

"How often do you feel the pain?"

"Can you point where is the pain is?"

"On the scale of the 0 until 10, with 0 no pain and 10 is the worst pain, would you rate the pain?"

" How long have you been in pain?"

"I need to check your vital signs before reporting this to the doctor, I will teach you the deep
breathing relaxation techniques to reduce your pain."

"I need to take yourtemperature now. Can I put this under your tongue please? Great, 37.2, that’s
fine. Now I need to take your pulse as well, if that’s okay?"

"I’m just going to rest your hand on your chest here, so it’s more comfortable while I take your
pulse."

"It’s 80. That’s fine. You'll have an ECG later on, so that just leaves your blood pressure. Have
you had this done before?"

"Okay, if you can just take off your jacket and roll up your sleeve for me ... as far as it will go ...

that’ll do. I’ll explain what I’m doing as we go along; people tend to feel better when they know

what to expect. I’m going to ask you to place your arm on the pillow first, and then I want you to
relax and just breathe normally. Now, if I can wrap this cuff around your arm ... That’s it. Now

I’ll just pump it up a little. You won’t feel any discomfort, just a little pressure to the arm. Okay

so far?"

"I’ll just have a listen while I release the pressure. Okay, that’s one thirty five over ninety."

"Well, it is a little higher than I would have thought. It could be due to your anxiety, which is

understandable. If you don’t mind though, I think I’ll take a second reading, just to be sure. Can

you give me your other arm please? Now, I need you to relax as much as possible. Good. All

done. There’s a slight decrease there, a hundred and thirty over eighty five, but it’s still a little

higher than normal."

"It varies, but normal blood pressure is generally below one hundred and twenty over eighty."

"Please repeat after me. Inhale through the nose to hold 3 seconds 1....2...3 then slowly exhale
through the mouth."

"Good."

3. Termination Phase

"Okay miss. How are you feeling after takes deep breathing?"

"Can you repeat it again?"

"Good. You can do that technique when you're in pain."

"Okay, I will report your condition to the doctor. If you need me can call me or press the button.
I will comeback in on hour 12 p.m to give your lunch, okay miss take a rest."