Acute Pain and Ineffective Breathing Pattern related to Pancreatitis (Nursing Interventions)

Nursing Interventions for Pancreatitis 

1. Acute pain related to: inflammation, edema, distention of the pancreas and irritation of the peritoneum

Subjective Data: Report verbally

Objective Data:

• Pain-bearing position
• Cautious behavior
• Sleep disturbances (glazed eyes, looking tired, difficult or disorganized movements, grinning)
• Autonomic responses (such as diaphoresis, changes in blood pressure, changes in breathing, pulse and pupil dilation)
• Expressive behavior (e.g. restlessness, moaning, crying, alert, irritable, long breathing/complaining)
• Changes in appetite and drinking

NOC :

• Pain level,
• Pain control,
• Comfort level

After 2x24 hours of nursing action, the patient does not experience pain, with the following criteria:

• Able to control pain (know the cause of pain, able to use non-pharmacological techniques to reduce pain, seek help)
• Reports that pain is reduced by using pain management
• Able to recognize pain (scale, intensity, frequency and signs of pain)
• Express a sense of comfort after the pain is reduced
• Vital signs within normal range

NIC

• Perform a comprehensive pain assessment including location, characteristics, duration, frequency, quality and precipitation factors.
• Observe nonverbal reactions to discomfort.
• Help patients and families to seek and find support.
• Environmental controls that can affect pain such as room temperature, lighting and noise.
• Reduce pain precipitating factors.
• Assess type and source of pain to determine intervention.
• Teach about non-pharmacological techniques: deep breathing, relaxation, distraction, warm / cold compresses.
• Give analgesics to reduce pain.
• Increase rest.
• Provide information about pain such as the cause of the pain, how long it will take for the pain to subside and anticipated discomfort from the procedure.
• Monitor vital signs before and after the first analgesic administration.

2. Ineffective breathing pattern related to: acute pain, pulmonary infiltrates, pleural effusion and atelectasis.

Subjective Data: Dyspnea and shortness of breath

Objective Data:

• Decreased inspiratory/expiratory pressure.
• Decreased air exchange per minute.
• Use the accessory respiratory muscles.
• Orthopnea.
• The expiration stage lasts a very long time.
• Decreased vital capacity.
• Respiration : < 11 –24 x /min

NOC:

• Respiratory status : Ventilation
• Respiratory status : Airway patency
• Vital sign Status

After nursing actions for 2x24 hours the patient shows the effectiveness of the breathing pattern, as evidenced by the outcome criteria:

• Demonstrating an effective cough and clean breath sounds, no cyanosis and dyspnea (able to expel sputum, able to breathe easily, no pursed lips).
• Demonstrate a patent airway (client does not feel suffocated, breath rhythm, respiratory rate within normal range, no abnormal breath sounds)
• Vital signs within normal range (blood pressure, pulse, respiration).

NIC:

• Position the patient to maximize ventilation.
• Perform chest physiotherapy if necessary.
• Remove secretions by coughing or suction.
• Auscultate breath sounds, note the presence of additional sounds.
• Give a bronchodilator:
• Give a humidifier Moist NaCl wet gauze
• Adjust intake for optimal fluid balance.
• Monitor respiration and oxygenation status.
• Clean the mouth, nose and tracheal secretions.
• Maintain a patent airway.
• Observe for signs of hypoventilation.
• Monitor the patient's anxiety about oxygenation.
• Monitor vital signs.
• Inform patient and family about relaxation techniques to improve breathing patterns.
• Teach how to cough effectively.
• Monitor breathing patterns.