Possibly evidenced by
Reports of pleuritic chest pain, headache, muscle or joint pain
Guarding of affected area
Distraction behaviors, restlessness
Desired Outcomes/Evaluation Criteria—Client Will
Verbalize relief or control of pain.
Demonstrate relaxed manner, resting, sleeping, and engaging in activity appropriately.
Nursing intervention with rationale:
1. Determine pain characteristics, such as sharp, constant, and stabbing. Investigate changes in character, location, and intensity of pain.
Rationale: Chest pain, usually present to some degree with pneumonia, may also herald the onset of complications of pneumonia, such as pericarditis and endocarditis.
2. Monitor vital signs.
Rationale: Changes in heart rate or blood pressure (BP) may indicate that client is experiencing pain, especially when other reasons for changes in vital signs have been ruled out.
3. Provide comfort measures, such as back rubs, change of position, and quiet music or conversation. Encourage use of relaxation and breathing exercises.
Rationale: Nonanalgesic measures administered with a gentle touch can lessen discomfort and augment therapeutic effects of analgesics. Client involvement in pain control measures promotes
independence and enhances sense of well-being.
4. Offer frequent oral hygiene.
Rationale: Mouth breathing and oxygen therapy can irritate and dry out mucous membranes, potentiating general discomfort.
5. Instruct and assist client in chest-splinting techniques during coughing episodes.
Rationale: Aids in control of chest discomfort while enhancing effectiveness of cough effort.
6. Administer analgesics and antitussives, as indicated.
Rationale: These medications may be used to suppress nonproductive or paroxysmal cough or reduce excess mucus, thereby enhancing general comfort and rest.