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Acute Pain Nursing Care Plan for Peritonitis

Nursing Diagnosis for Peritonitis : Acute Pain related to inflammatory processes, fever and tissue damage.

Acute Pain NANDA Definition : Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months

Characteristics :

  • Patient reports pain
  • Guarding behavior, protecting body part
  • Self-focused
  • Narrowed focus (e.g., altered time perception, withdrawal from social or physical contact)
  • Relief or distraction behavior (e.g., moaning, crying, pacing, seeking out other people or activities, restlessness)
  • Facial mask of pain
  • Alteration in muscle tone: listlessness or flaccidness; rigidity or tension
  • Autonomic responses (e.g., diaphoresis; change in blood pressure [BP], pulse rate; pupillary dilation; change in respiratory rate; pallor; nausea)

Goal :
Pain is reduced / no pain

Expected outcomes:

  • Report: no pain / controlled
  • Demonstrate use of relaxation skills.
  • Another method to improve comfort

Nursing Interventions Acute Pain Nursing Care Plan for Peritonitis

Independent:

1. Investigate reports of pain, noting location, duration, intensity (scale 0-10) and characteristics (shallow, sharp, constant)
Rationale: The change in location / intensity not common but may indicate the occurrence of complications. Pain tends to be constant, more intense, and spread upward, pain can occur if local abscess.

2. Maintain semi-Fowler’s position as indicated
Rationale: Facilitate drainage of fluids / injury, because of gravity and helps minimize the pain due to movement.

3. Provide comfort measures, sample the back massage, deep breathing, relaxation or visualization exercises.
Rationale: Increase relaxation and may enhance the patient’s coping abilities by refocusing attention.

4. Provide oral care. Eliminate unpleasant environmental stimuli.
Rational: Lowering nausea / vomiting that can increase the pressure or pain intrabdomen.

Collaboration:

Give medications as indicated:

  • Analgesic
  • Antiemetics
  • Antipyretic

Rational: Lowering the metabolic rate and irritable bowel because of toxin circulating / local, which helps relieve pain and improve healing.

Reduces nausea / vomiting, which can increase abdominal pain

Lowering of discomfort related to fever or chills.