CUES NURSING SCIENTIFIC OBJECTIVE INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION

S: “ Sumasakit ang Acute Pain related to Alcoholism STG: 1. Monitor vital signs. 1. Alteration from normal Goal met.
tiyan ko hanggang sa inflammation of ↓ After 1 hour of maybe signs of infection. The patient was able to
likod ko” as pancreatic capsule Pancreatic duct rendering care improve as evidenced by
verbalized by the and activation of obstruction patient’s condition 2. Provide comfort 2. To promote non demonstrating ability to
patient. psecondary to ↓ will improve as measures such as pharmacological pain take medication given
autodigestion Premature activation evidenced by touch, repositioning, management. appropriately and ability
O: of enzyme demonstrating ability quiet environment and to cope with
-facial grimace ↓ to take medication calm activities. incompletely relieved
-guarding behavior Autodigestion given appropriately pain manifested by
-irritability ↓ and ability to cope 3. Encourage patient to 3. Promotes cooperation reduced protective
Inflammation with incompletely verbalize about pain. from the patient. gestures & irritability.
M: ↓ relieved pain
Painscale of 8 out of Movement of ion manifested by reduced 4. Encourage 4. To distract attention LTG:
10 across the cell protective gestures & diversional activities and reduce tension. The patient was able to
BP: 94/60mmhg membrane irritability. and relaxation demonstrate no signs of
PR: 92bpm ↓ techniques such as pain as evidenced by
RR: 22cpm Excite the nociceptor LTG: focused breathing and verbalization of mild or
T: 37.6C ↓ After 2 days of imaging. no report of pain and
Peripheral nerve rendering care patient absence of facial
fibers will demonstrate no 5. Administer demerol 5. To maintain acceptable grimace, irritability &
↓ signs of pain as as ordered. level of pain. protective gestures
Dorsal horn of spinal evidenced by
cord verbalization of mild
↓ or no report of pain
Spinothalamic tract and absence of facial
↓ grimace, irritability &
Brainstem and protective gestures
thalamus
↓
Somatic sensory
cortex
↓
PAIN