UNIT 3 (AHN SEM-III) and its treatment - new.ppt

adult health nursing

2. Fluid and Electrolyte Imbalance
At the end of the unit students will be able to-
•Identify the signs & symptoms of shock and electrolyte imbalances.
•Develop skills in managing fluid and electrolyte imbalances.
•Perform pain assessment and plans for the nursing management.

3. Fluid and electrolyte Disturbance
Amount and Composition of Body Fluids:
-Approximately 60% of a typical adult’s weight consists of
fluid (water & electrolyte).
-Body fluid is located in two fluid compartments:
1) Intracellular fluids(fluids in the cells) 2/3.
2) Extracellulerfluids:(fluids out side the cells) 1/3.
a-Intravascular space (fluids with in blood vessels)
contains plasma.
b-Interstitialfluids: contain fluids that surround the cell. Eg. Lymph.
c-Transcellularspace: fluid contained in compartments.
eg. Cerebrospinal, Pericardial, Synovial.

4. Average daily intake and output in an adult:
Intake Output
•Oral Liquids :1300ml. Urine :1500ml
•Water in foods :1000ml. Stool : 200ml
•Water produced Insensible lungs: 300ml
•by metabolism : 300ml Skin 600ml
2600ml 2600ml

5. Normal Lab Results:
-Na→ 135−145mEq/L.
-K+ → 3.5−5.5mEq/L.
-Ca++→ 8.5−10.5mEq/L.
-Cl → 96−106mEq/L.
-Mg→ 1.5−2.5mEq/L.

6. Fluid Volume Disturbance:
I-Hypovolemia (fluids volume deficit):
− Contributing Factors:
*Loss of water and electrolyte.
e.g.( vomiting, diarrhea, burns).
*Decreased intake. e.g. (anorexia, nausea, inability to
gain access to fluids).
* Some diseases. e.g. (D.M, Diabetes Insipidus).
− Signs and symptoms:
Weight loss, general weakness, dizziness, tachycardia.

7. •Assessment Diagnostic evaluation
•Health History & Physical examination
•Serum BUN & Creatinine
•Hematocrit level “great than normal”
•Urine specific gravity
•Blood osmolarity
•Weight loss

9. ♣Management
•factors influencing the ptfluid needs should be taken in
consideration
•In case of severe or acute FVD, IV replacement should be
started
•Isotonic solutions used to treat hypotension resulted from
FVD
•Renal function & hemodynamic status should be evaluated.
♣Nursing Management
•Monitor I&O as needed.
•Monitor Vital signs, skin turgor, mental status & daily weight
•Mouth care
•Parenteral therapy-TPN

10. Fluid Volume Disturbance:
II-Hypervolemia (fluid volume excess):
− Contributing Factors:
* Compromised regulatory mechanism such as renal failure, congestive
heart failure, and cirrhosis.
* Administration of Na+ containing fluids.
* Prolong corticosteroid therapy.
*Increase fluid intake.
− Signs and Symptoms:
•Weight gain
•increase blood pressure
•Edema
•shortness of breathing.
•Bounding pulse

11. Assessment & Diagnostic Evaluation
-Decreased BUN, Creatinine
-Decreased Serum osmolality & hematocrit
because of plasma dilution& ↓protein intake
-Urine sodium is increased if kidneys excrete
excess fluid

13. Management
Direct cause should be treated
Symptomatic treatment consist of :
-Diuretics
-restrict fluid & Na intake
-Maintain electrolytes balance
-Hemodialysis in case of renal impairment
-K+ supplement & specific nutrition
Nursing Management:
-Assess breathing , weight ,degree of edema regularly
-I & O measurement regularly
-Semi-fowlers position in case of shortness of breath
-Patient education

14. Electrolyte imbalance:
I-Sodium Deficit (Hyponatremia):
−Contributing Factors:
* Use of a diuretic.
* Loss of GI fluids.
* Gain of water.
− Signs and Symptoms:
•Hypotension
•nausea and vomiting
•Headache
•Lethargy
•Confusion
•seizures.
•Diminished deep tendon reflexes

15. Hyponatremia
•Treatment:
•Fluid restriction, +diuretics
•Diet-Sodium rich diet
•IV Fluid-Inj. NS 0.9% (Isotonic), Inj. NS 3% (Hypertonic)
•Avoid sudden rise-5 to 8 mEq/L in 24 hours

16. Electrolyte imbalance:
II-Sodium Excess (Hypernatremia):
− Contributing Factors:
* Water deprivation in patient.
* Hypertonic tube feeding.
* Diabetes Insipidus.
− Signs and Symptoms:
•Hypertension
•Thirst
•Dry skin
•Altered cerebral function
•Tachycardia

17. Hypernatremia
•Treatment: correct underlying disorder
•Free water replacement-150-200ml per Q2H
•Slow infusion of D5W -give ½over first 8 hrs then rest over next 16-24
hrs to avoid cerebral edema.
•IV infusion of NS should be stopped
•Dilution of drugs in Half saline

18. Electrolyte imbalance:
III-Potassium Deficit (Hypokalemia):
− Contributing factors:
* Low intake of potassium from diet
* Diarrhea, vomiting, gastric suctions.(increased excretion)
* Corticosteroid administration.
* Diuretics.
− Sign and symptoms:
•muscle weakness
•Cardiac dysrhythmias
•N&V
•Deep tendon reflexes become hypoactive
•changes in ECG.
flat T-waves, ST depression, and U waves

19. Hypokalemia, continued
•ECG changes in hypokalemia

20. Hypokalemia
•Treatment:
•Check renal function
•Treat alkalosis
•Potassium rich diet
•Oral supplements-Syp Potchlor (max. 15ml at a time)
•IV injection of KCl : peripheral 7.5 mEq/hr, central 20 mEq/hr

21. Electrolyte imbalance:
IV-Potassium Excess (Hyperkalemia):
− Contributing Factors:
* Renal Failure.
* Crush injury, burns.
* Blood transfusion.
* Administration of IV K+.
− Sign and Symptoms:
Bradycardia, dysarrythmia, anxiety, irritable.
-ECG: peaked T waves then flat P waves, depressed ST segment,
widened QRS progressing to sine wave and V fib.

22. Hyperkalemia –ECG Changes

23. Hyperkalemia, continued
Treatment:
Remove iatrogenic causes
Acute: if > 7.5 mEq/L or EKG changes
Ca-gluconate–1 gm over 2 min IV
Sodium bicarbonate –1 amp, may repeat in
15min
D50W (1 ampule = 50 gm) and 10U regular
insulin
Emergent dialysis
Hydration and diuresis
kayaxalate(K+ sparing sachet)
Nebulization with Salbutamol

24. Calcium
Hypocalcemia:
Decreased intake of Ca
Often symptomatic below 8 mEq/dL
Check PTH:
Vitamin D deficiency, hypoparathyroidism, massive blood
transfusion, drugs (e.g. gentamicin) renal insufficiency
S/S
numbness, tingling, circumoralparesthesia, cramps tetany, increased
DTR’s, Chvostek’ssign, Trousseau’s sign
EKG has prolonged QT interval & prolonged ST segment

26. Calcium
•Hypocalcemiacont.
•Treatment:
•Calcium rich diet
•Stop frusemide
•Acute: (IV) Calcium Gluconate10cc of 10% solution
•Chronic: (P/O) 0.5-1.25gm CaCO
3= 200-500 mg Ca.
•VitD (calciferol) must have normal serum level
•Avoid phosphate rich diet

27. Calcium
Hypercalcemia
Increased intake of Carich diet
Decreased excretion of Ca-causes are thiazides
Acute adrenal insufficiency
Hypophosphataemia
Hyperparathyroidism
Acute crisis is serum Ca> 12mg/dL. Critical at 16-20mg/dL
S/S:
N/V, anorexia
Decreased gastric motility
Urinary stones
Diminished Deep tendon reflexes
Constipation

28. Calcium
•Treatment:
•Hydration with NS
•Administer loop diuretic
•Phosphate diet increased
•Calcitonin

29. Magnesium
Hypomagnesemia
•Decreased intake of magnesium
•Burns
•Pancreatitis
•Parathyroidectomy
•Chronic alcoholism
•Primary hyperaldosteronism
S/S:
•weakness, fatigue, Cramps, hyperreflexia, seizure, Chvostek’ssign and Trosseau’ssign
Treatment:
•IV replacement of 2-4 gm of MgSO4 per day or oral replacement

30. Magnesium
•Hypermagnesemia
•Renal insufficiency
•adrenal insufficiency
•Hypoparathyroidism
•Iatrogenic
•Laxatives & Antacids us (that contain Magnseium)-Gelusil
S/S:
•N/V, muscle weakness, hyporeflexia, paralysis of voluntary muscles.
Treatment:
•Discontinue source
•IV CaGluconatefor acute treatment
•Dialysis

31. Acid−Base Disturbance:
Normal Values:
PH→ 7.35-7.45.
PCO2→ 35-45mmHg.
PO2→ 80-100mmHg.
HCO3→ 22-26mEq/L.
Respiratory Acidosis: → → → → ↑ PCO2.
Respiratory Alkalosis: → → → → ↓ PCO2.
Metabolic Acidosis: → → → → ↓ PH, ↓ HCO3.
Metabolic Alkalosis: → → → → ↑ PH, ↑ HCO3.

32. SHOCK

33. TYPES OF
SHOCK
HYPOVOLE
MIC SHOCK
CARDIOGENIC
SHOCK
CIRCULATOR
Y SHOCK
SEPTIC
SHOCK
Organizational Chart
Back to Agenda
Page
NEUROGE
NIC SHOCK
ANAPHY
LA-CTIC
SHOCK

34. •This is the most common type of shock and based on the insufficient
circulatory volume.
•Primary cause is loss of fluid from circulation from either an internal or external
source.
•Hypovolemic shock occurs when there is a reduction in intravascular volume
by 15% to 30% which represents a loss of 750 ml to 1500 ml of blood in a 70
kg person.
HYPOVOLEMIC
SHOCK

35. RISK FACTORS FOR HYPOVOLEMIC SHOCK
1. EXTERNAL :
• Trauma
• Surgery
• Vomiting
• Diarrhoea
• Diuretics
• Diabetes Insipidus
• External bleeding
2.INTERNAL:
• Haemorrhage
• Burns
• Ascites
• Peritonitis
• Internal
bleeding

36. Due to etiological factor
↓
Loss of body fluids and bloods
↓
Decrease cardiac output
Hypo perfusion
Compensatory mechanism
↓
PATHOPHYSIOLOGY OF HYPOVOLEMIC
SHOCK:

37. Norepinephrineand
Epinephrine
Increaseheartrateand
vascularresistance
Renin angiotensin and
aldosterone stimulation
Intracellular fluid shift to
intravascular space
ADH
release
Increase blood volume
Increase cardiac output

38. Compensatory mechanism fails
Decrease cardiac output
Decrease blood pressure
↓
Decrease perfusion to the vital
organs
↓
Multisystem organ failure

39. MEDICAL
MANAGEME
NT
1. Treatment of the underlying cause
2. Fluid and blood replacement
• Crystalloids-0.9% sodium chloride
• Ringer lactate solution
• Hypertonic saline
• Colloids (Albumin, Dextran)
3. Redistribution of fluid
4. Pharmacologic therapy
(Vasoactive agents, Insulin therapy,
Desmopressin, Antidiarrhoeal,
Antiemetics).

40. NURSING MANAGEMENT
•Primary prevention of shock is an essential focus of nursing
care.
1. Administering blood and fluids safety:
• Administration of blood transfusion.
• Blood specimens, cross matching of the blood should be done.
• Patient should be monitored for cardiovascular overload
• Hemodynamic pressure, vital signs, arterial blood gases, serum
lactate levels, hematocrit and hemoglobin level need to be
monitored.

41. • Maintain temperature
• Observing jugular venous pressure for distension
•The nurse must monitor cardiac and respiratory status
2. Implementing other measures
• Oxygen is administered.
•Patient may be irritated and apprehensive so frequent
explanations about the patient's condition may reduce some of the
patient's fear and anxiety.

42. CARDIOGENIC
SHOCK
•Cardiogenic shock occurs when the heart's ability to
contract and to pump blood is impaired and the supply of
oxygen is inadequate for the heart and tissues.
•Coronary cardiogenic shock is more common than the non
coronary cardiogenic shock.
•Non coronary causes of cardiogenic shock are the
conditions that stress the myocardium such as severe
hypoxemia, acidosis, hypoglycaemia, hypocalcaemia,
tension pneumothorax, cardiomyopathies, cardiac
temponade, dysrhythmias.

43. CLINICAL
MANIFESTATION
S:
•Distended jugular vein due
to increased jugular venous
pressure.
•Absent pulse due to
tachyarrhythmia
•Anginalpain
•Dysrhythmias.
•Complain of fatigue
•Express feelings of doom
•Signs of hemodynamic
instability.

44. 2. Impaired heart's ability to contract and pump blood.
Decrease stroke volume Increase pulmonary pressure
Decrease cardiac output pulmonary edema
Decrease oxygenation to the tissues.
PATHOPHYSIOLOGY
1. Myocardial infarction, arrhythmias, congestive heart failure,
cardiac myopathy, cardiac valve problem.

45. Hypo-perfusion of tissues
Impaired cellular metabolism.

46. MEDICAL MANAGEMENT
The goals of medical management in cardiogenic shock are to
limit further myocardial damage and preserve the healthy
myocardium and to improve the cardiac function.
1. Correction of underlying causes.
2. Initiation of first line treatment.
• Oxygenation.
• Pain control.
• Hemodynamic monitoring
• Laboratory marker monitoring.
• Fluid therapy.

47. Pharmacologic treatment :-
> Dobutamine.
> Nitroglycerine.
> Dopamine.
> Antiarrhythmic medications.
> Other vasoactive medication.
> Mechanical assistive devices.

48. NURSING MANAGEMENT
1. Preventing cardiogenic shock
2. Monitoring hemodynamic status.
3. Administering medications and intravenous fluids.
4. Maintaining intra-aortic balloon counter pulsation.
5. Enhancing safety and comfort.

49. CIRCULATORY SHOCK
•Circulatory shock occurs when blood volume pooled in
peripheral blood vessels and results in hypovolemia which
leads to inadequate tissue perfusion.
•Contractility of the heart helps the blood to return to the heart.
And the vascular tone is determined by central regulatory
mechanism (in BP regulation) and local regulatory mechanism
(in tissue demands for oxygen and nutrient)
•Thereby circulatory shock can be caused either by a loss of
sympathetic tone or by release of biochemical mediators from
cells.

50. PATHOPHYSIOLOGY :-
1. Precipitating event
2. Vasodilation
3. Activation of inflammatory response
4. Abnormal distribution of blood volume
5. Decreased venous return
6. Decreased cardiac output
7. Decreased tissue perfusion

51. CLASSIFICATION OF CIRCULATORY
SHOCK:
1. Septic shock
2. Neurogenic shock
3. Anaphylactic shock

52. 4. SEPTIC SHOCK
•The most common type of circulatory shock, is caused by
widespread of infection.
•The most common cause of death.
•The incidence can be reduced by using strict aseptic
technique, thorough hand hygiene techniques.
•Interventions include prevention of central line infection,
early debriding of wounds to remove the necrotic tissues,
carrying out standard precaution, adhering to infection
control practices, prompt cleaning and maintaining of
equipment.

53. PATHOPHYSIOLOGY
1.Severelocalizedinfectionofgramnegativebacili(E.Coli,
Klebsella)
2.Septicemia(invasionofbacteriaintothebloodstream)
3.Inflammatoryresponse
4.Releaseofendo-toxinintocirculation
5.Immunesystemreleaseshistamineandotherchemical
mediators.
Massivevasodilation Increasecapillarypermeability
6.Severebronchoconstriction

54. 7. Decrease oxygen supply to the tissues
8. Decrease tissue perfusion
9. Shock.

55. MEDICAL MANAGEMENT
1. Fluid replacement therapy
2. Pharmacolgic therapy
•Broad spectrum antibiotic
•Drotrecogin alfa (acts as an anti-inflammatory cytokine, it
stimulates fibrinolysis, restoring balance in the coagulation -
anticoagulation homeostatic process of the body's
inflammatory response to injury and infection
3. Nutritional therapy (should start in first 24 hours after ICU
admission

56. NURSING MANAGEMENT : -
•All invasive procedure must be carried out with aseptic
technique.
•IV lines, arterial and venous puncture sites, surgical incision,
traumatic wounds, urinary catheter and pressure ulcers must
be monitored for signs of infection.
•Patients with elderly and immunosuppressive, extensive
trauma, burns, or diabetes should be given most attention.
•Elevated temperature is common in septic shock and increase
the metabolic rate so it should not be treated unless it reaches
to the dangerous level.

57. •The nurse administers prescribed IV fluids and medications
including antibiotic agents and vasoactive mediators to
restore vascular volume.
•Blood levels of BUN, creatinine, WBC, hemoglobin,
hematocrit, platelet levels, coagulation studies should be
monitored
•Fluid intake and output, nutritional status, daily weights
should be checked.
•Close monitoring of the serum albumin and pre-albumin
levels help determine the patients protein requirements.

58. NEUROGENIC SHOCK
•In neurogenic shock vasodilation occurs as a result of a loss
of balance between parasympathetic and sympathetic
stimulation.
•Sympathetic stimulation causes vascular smooth muscle to
constrict, and parasympathetic stimulation causes vascular
smooth muscle to relax or dilate.
•In neurogenic shock the sympathetic system not able to
respond to the body stressors. Therefore neurogenic shock
are signs of parasympathetic stimulation.
•Parasympathetic stimulation causes vasodilation that results
in hypovolemic state and gradually leads to hypotension and
shock.

59. ETIOLOGY:
• Spinal cord injury
• Spinal anesthesia
• Nervous system damage.
• Depressant action of medication

60. PATHOPHYSIOLOGY
1. Spinal cord injury, anaesthesia.
2. Loss of autonomic nervous system and motor function below the
level of injury
3. Loss of sympathetic control
4. Arterial or venous pooling
5. Dilatation of blood vessels
6. Hypotension
7. Warm, dry, flushed skin and bradycardia.
8. Decrease tissue perfusion to the vital organ
9. Multisystem organ failure.

61. MANAGEMENT : -
• Elevate the head of the bed at least 30 degree angle when the
patient receives spinal or epidural anaesthesia. Because it helps in
the prevention of the spread of anesthetic agent up the spinal
cord.
• Carefully immobilize the patient in case of patient with spinal
cord injury.
• Supporting of cardiovascular and neurologic function.
• Apply anti-embolism stockings.
• Elevate the foot end to prevent the venous pooling of the blood in
the legs because it may increase the risk of thrombus formation.

62. • The nurse must monitor the lower extremity pain, redness,
tenderness and warmth.
• Patient should be evaluated for deep vein thrombosis by
assessing the calf muscle pain.
• Administer heparin or low molecular weight heparin (lovenox) as
prescribed.
• Passive range of motion of the immobile extremities helps
promote circulation.
• The nurse must monitor the patient for signs of internal bleeding
that could lead to hypovolemic shock.

63. ANAPHYLACTIC SHOCK
• Anaphylactic shock occurs rapidly and is life
threatening.
• Anaphylactic shock occurs in patients who has
already exposed to an antigen and who have
developed antibodies to it.
•Caused by an severe anaphylactic reaction to an
allergen, antigen, drug, foreign protein causing the
release of histamine which causes vasodilation
leading to hypotension and increased capillary
permeability.

64. PATHOPHYSIOLOGY
1. Antigen re-exposure.
2. Hypersensitivity antibody response
3. Activation of mast cells
4. Release of vasoactive substances such as bradykinin,
histamine.
5. Arterial vasodilation
6. Increase capillary permeability
7. Severe bronchospasm
8. Decrease oxygen supply and increase demand of oxygen
9. Inadequate tissue perfusion
10. Shock and death.

65. MEDICAL MANAGEMENT
• Remove the causative antigen
• Emergency basic life support.
• Epinephrine is given for its vasoactive action
• Diphenydramine-to reverse the effects of histamine thereby
reducing the capillary permeability.
• Nebulized medication such as albutarol to reverse the
histamine induced bronchospasm.
•CPR in case of cardiac or respiratory arrest.
• Endotracheal intubation or tracheostomy to establish the
airway.

66. NURSING MANAGEMENT
•Check the vitals, respiration, BP and Mean arterial pressure.
•The nurse must assess for previous reaction of the allergy to
medication, blood products, foods, contrast agents.
•Observe patient for allergic reaction while administering the
medication.
•The nurse must identify patients who are at risk for
anaphylactic reactions to contrast agents used for diagnostic
tests.
•This information need to be communicated to the diagnostic
testing site.
•After recovery from anaphylaxis the patient and family require
an explanation of the event.

67. PAIN
ASSESSMENT

68. DEFINITION
Painisanunpleasantsensationandemotional
experiencethatlinkstotissuedamage.
-Internationalassociationforthestudyofpain(IASP)

69. TYPESOFPAIN
Acute pain –Short duration , healing process in 30 days.
Chronic pain–Its persist for the more than 3-6 month.
Physiological pain-it leads to potential tissue damage.
Somatic pain–It involves superficial tissues (skin, bone,
muscle, joints)
Visceral pain- It involves organs (heart, stomach
& liver)
Neuropathic pain–changes in the nerve cells.

70. ASSESSMENTOFPAIN
Assessmentofpainincludes,
Subjectivedata
Objectivedata

71. SUBJECTIVEDATA
1.PAIN HISTORY:
while taking pain history , nurse must provide an
opportunity for clients to express their own words, how
they view it and their situation.
This is will help the nurse to identify patient pain and
how to cope up with it.

72. SUBJECTIVEDATA
2.ONSETANDDURATIONOF OCCURRENCE:
Whendidpainbegin?
Howlonghasitlasted?
Doesit occuratsametimeeach day?
Howoftendoesitoccurs?

73. SUBJECTIVEDATA
3.LOCATION:
In which area it is felt? Do the area differ under different
circumstances?
If several parts of body are painful, do pain occur simultaneously?
Is pain unilateral/ bilateral?
Ask the individual to point site of discomfort?

74. SUBJECTIVEDATA
4.INTENSITY:
Use of pain intensity scale is an easy and reliable method of
determining the clients pain intensity.
Most scales are either 0 to 5 or 0 to 10
Currently used scales are:
Numerical scale
Descriptive scale Visual analog scale

75. TYPESOFPAINSCALE
1.DESCRIPTIVESCALE
2.NUMERICAL SCALE
3.VISUALANALOGSCALE

76. PAINASSESSMENTSCALE
1.Numerical rating scale:
A numerical rating scale with the range of 0 to 10 is a type
of pain scale that is used.
The word ‘no pain’ appear by “0” and “worst pain
possible” is found by “10”.
Patient are asked to choose a number from 0 to 10 that
best reflects his/her level of pain.

77. NUMERICALRATINGSCALE

78. PAINSCALE
2. Verbal rating scale:
Verbal pain scales as name suggest, use words to
describe pain. Word such as no pain, mild pain,
moderate pain and severe pain are used to
describe pain levels.

79. PAINSCALE
3.Visual analogue scales:
⚫VAS use a vertical or horizontal line with words that
convey “no pain” at one end and “worst pain” at opposite
end.
⚫Patient is asked to place a mark along line that
indicates his/her level of pain.

80. VISUALANALOGSCALE

81. PAIN SCALE

82. NURSINGASSESSMENT
Assess the patients risk for pain (Ex. Those
undergoing invasive procedures, anxious patients)
Assess the patient response to previous
pharmacological interventions, especially ability to
function.
Examine the site of patients pain or discomfort.
Assess for physical, behavioral and emotion signs
and symptoms of pain:
(moaning, decreased activity, abnormal guilt and
irritability)

83. OBJECTIVEDATA

84. OBJECTIVEDATA

85. PREPARATIONOFEQUIPMENTS
1.Painscale
2.Privacyscreenasperneed
3.Patient casesheet

86. NURSINGPROCEDURE

87. NURSINGPROCED RE
S. NONURSING PROCEDURE ACTION
1. Explain the procedure to the
patient.
Promotes compliance.
2. Wash hand and wear gloves if needed.To prevent
transmission of
microorganisms.
3. Provide privacy if needed. To provide comfort.
4. Ensure presence of easy lighting.For easy assessment.
5. Assess the level of pain using a
pain scale in the following method:
•assess characteristics of pain, using
PQRSTUof pain assessment:
Provocative/palliative factors-
whatmakesyourpainbetteror
worse?

88. Quality –tell me what your pain
feels like?
Region / radiation –show me
where your pain is. Where is the
pain spreading to?
Severity –using a pain
intensity scale appropriate to the
patient age, developmental level,
and comprehension , ask the
patient to rate the pain, it has to be
related in descriptive and
numerical scale for adults and
visual analog for children.
Timing –ask the patient if
pain is continuous, intermittent,
constant or a combination.
Ask the patient , “ how is the pain
affecting you?”

89. 6. Ask the remedial non-
pharmacological and
pharmacological taken at home and
in the hospital.
To decide the care to
be given and the avoid
duplication of care.
7. Mark it in the pain assessment form.Serves as an evidence
for the care.
8. Perform hand hygiene and
discard gloves, if used.
Reduces transmission
of infections.

90. RECORDING&REPORTING
Record and report the character of pain before
intervention, therapies used and patients response.

91. THANKYOU