NCP for Glaucoma
Nursing Diagnosis and Interventions - Acute Pain
Nursing Diagnosis :
Acute pain related to Increased intraocular pressure (IOP) which is characterized by nausea and vomiting.
Subjective Data :
- Report verbally
Objective Data:
- Position holding pain
- Cautious behavior
- Sleep disturbances (glazed eyes, looking tired, difficult or chaotic movements, grinning)
- Focused on self
- Narrowed focus (decreased perception of time, impaired thought processes, decreased interaction with other people and the environment)
- Distraction behavior, pattern: walking, meeting other people and/or activities, repetitive activities)
- Autonomic responses (such as diaphoresis, changes in blood pressure, changes in breathing, pulse and pupil dilation)
- Autonomic changes in muscle tone (may range from weak to stiff)
- Expressive behavior (example: restless, moaning, crying, alert, irritable, long breath/complaining)
- Changes in appetite and drinking.
Nursing Interventions:
Goals / Outcome Criteria:
NOC :
v Pain Levels,
v Pain control,
v Comfort level
After nursing actions for... The patient does not experience pain, with the outcome criteria:
- Able to control pain (know the cause of pain, can use non-pharmacological techniques to reduce pain, seek help)
- Reported that pain was reduced by using pain administration
- 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
- No sleep disturbances
NICs :
- Perform a comprehensive pain assessment including location, characteristics, duration, frequency, quality and precipitation factors
- Observe nonverbal reactions to discomfort
- Help patients and families find support
- Environmental controls that can affect pain such as room temperature, lighting and noise
- Reduce pain precipitating factor
- Assess type and source of pain to select 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 the pain will decrease and anticipate discomfort from the procedure
- Monitor vital signs before and after the first analgesic administration
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