CUES NURSING INFERENCES PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS

SUBJECTIVE: Acute pain Unrelieved GOAL: INDEPENDENT: INDEPENDENT: EFFECTIVENESS:

- Patient related to acute pain leads After 8 hours of 1. Instruct client to 1. Unrelieved pain Was the patient able to
verbalized physical to debilitation, nursing report any can create other experience gradual
“Masakit agent and diminished interventions, the improvement/exac problems such as reduction/relief of pain
yung tuhod inflammatory quality of life, patient will be er-bation in pain anger, anxiety, after 8 hours of nursing
ko, yung process and depression. able to experience experience. immobility, interventions?
parte na secondary to Unrelieved gradual respiratory __yes __no
may insertion of acute reduction/relief of problems, and why?
nakatusok,” Steinmann postoperative pain. delay in healing.
- Verbalized pin and pain leads to (Medical-Surgical Was the patient able to
“Namaman presence of development of OBJECTIVES: Nursing, 7th ed. by verbalize reduction/relief
hid yung arthritis chronic pain After the series of Black, Joyce M. of pain after the series of
tuhod ko, respectively syndromes and nursing and Jane nursing interventions?
parang may increased interventions, the Hokanson Hawks; __yes __no
tumutusok, complications. patient will be p. 443) why?
pasumpong In fact, able to:
-sumpong unrelieved pain 2. Encourage 2. Only the client can Was the patient able to
sya.” can kill. 1. verbalize verbalization of judge the level and have normal respiratory
- Verbalized reduction/ feelings about the distress of pain; rate after the series of
“Mas Source: relief of pain. pain. pain management nursing interventions??
masakit Medical- should be a team __yes __no
yung Surgical 2. have normal approach that why?
th
rayuma ko Nursing, 7 ed. Respiratory includes the client.
sa kaliwang by Black, Joyce Rate. Very few people lie Was the patient able to
kamay, M. and Jane about pain. move his left upper
pasumpong Hokanson 3. move his left (Medical-Surgical extremity without facial
-sumpong Hawks; p. 440 upper Nursing, 7th ed. by grimace after the series
sya.” extremity Black, Joyce M. of nursing interventions?
- Verbalized without facial and Jane __yes __no
“Masakit grimace Hokanson Hawks; why?
 yung Etiology of p. 443)
rayuma ko Acute Pain 4. have no facial Was the patient able to
lalo na pag from the Site grimace upon 3. Provide comfort 3. To provide have no facial grimace
ginagalaw of Steinmann palpation of measures such as nonpharmacologic upon palpation of the
ko; lagi Pin Insertion: the wrist use of incentive pain management. wrist after the series of
syang spirometry or blow (Nurse’s Pocket nursing interventions?
kumikirot.” Immediate 5. recite the bottles. Guide, 9th ed. by __yes __no
cause: nonpharmacol Doenges, why?
OBJECTIVE: Activation of ogic ways to Marilynn, et.al., p.
- Pain scale nociceptors or lessen pain. 368) Was the patient able to
of 10 for pain receptors recite the
arthritis on 6. demonstrate 4. Encourage 4. The human body nonpharmacologic ways
left wrist Intermediate the relatives to is believed to have to lessen pain after the
- Pain scale cause: nonpharmacol perform touch energy fields that series of nursing
of 2 for site Break in the ogic ways to therapy. express aberrant interventions?
of skin integrity lessen pain. patterns when body __yes __no
Steinmann systems are why?
pin Root cause: insulted.
insertion Insertion of Therapeutic Touch Was the patient able to
- RR: 21 Steinmann pin is thought to demonstrate the
cpm realign aberrant nonpharmacologic ways
- Exhibited Etiology of fields. (Medical- to lessen pain after the
facial Pain on Left Surgical Nursing, series of nursing
th
grimace Wrist: 7 ed. by Black, interventions?
upon Joyce M. and Jane __yes __no
movement Immediate Hokanson Hawks; why?
of the left cause: p. 480)
upper Activation of EFFICIENCY:
extremity nociceptors or 5. Encourage and 5. Deep breathing for Were the human
- Exhibited pain receptors assist client to do relaxation is easy resources, materials and
facial deep breathing to learn and time used economically?
grimace Intermediate exercises. contributes to pain __yes __no
upon cause: relief and/or why?
palpation Inflammatory reduction by
of the wrist process reducing muscle APPROPRIATENESS:
tension and Were the interventions
Root cause: anxiety. (Medical- suitable to client’s
Presence of an Surgical Nursing, situation?
underlying 7th ed. by Black, __yes __no
disease/ Joyce M. and Jane why?
condition Hokanson Hawks;
(Rheumatoid p. 479) Were the setting and
and Gouty 6. Provide 6. If the client is ill, time table interventions
arthritis) psychological ascertain the realistic to client’s
support/motivation motivation for situation?
. returning to an __yes __no
optimal level of why?
wellness.
(Medical-Surgical ACCEPTABILITY:
Nursing, 7th ed. by Were the interventions
Black, Joyce M. accepted by the patient
and Jane (without any signs of
Hokanson Hawks; rejection from the patient
p. 75) and family members)?
__yes __no
7. Encourage 7. To promote why?
mobilization of the circulation and
left upper prevent excessive ADEQUACY:
extremity. Assist tissue pressure. Was the number of
with ROM (Fundamentals of interventions sufficient
exercises. Nursing 7th ed. by to meet the desired goal
Kozier, Barbara, p. and objectives?
535) __yes __no
why?
8. Encourage 8. To prevent fatigue.
adequate periods (Nurse’s Pocket
 of rest and sleep, Guide, 9th ed. by
including Doenges,
uninterrupted Marilynn, et.al., p.
periods of 369)
sufficient duration,
meeting comfort
needs, limiting/
avoiding use of
caffeine/ alcohol
and medications
affecting REM
sleep. Encourage
quiet, restful
atmosphere.

9. Discuss with 9. Promotes early

relatives the detection of
importance of developing
early detection and complications.
reporting of (Fundamentals of
changes in Nursing 7th ed. by
condition or any Kozier, Barbara, p.
unusual physical 536)
discomforts/
changes.

10. Teach the client 10. It may be possible

and significant to teach clients a
others about the combination of
nonpharmacologic these techniques to
ways to lessen maximize their
pain. opportunities for
self-control over
 manifestations of
pain. (Medical-
Surgical Nursing,
7th ed. by Black,
Joyce M. and Jane
Hokanson Hawks;
p. 476)

11. To meet pain

11. Notify physician if control goal.
regimen is (Nurse’s Pocket
inadequate. Guide, 9th ed. by
Doenges,
Marilynn, et.al., p.
368)

COLLABORATIVE:
COLLABORATIVE: 1. Necessary for
1. Administer treatment of the
medications underlying cause.
(particularly (Nurse’s Pocket
analgesics) as Guide, 9th ed. by
prescribed. Doenges,
Marilynn, et.al., p.
542)
To maintain
acceptable level of
pain. (Nurse’s Pocket
Guide, 9th ed. by
Doenges, Marilynn,
et.al., p. 368)
2. To determine
changes indicative
2. Assist with of healing/
laboratory/diagnos infection/
tic studies as complications. To
indicated. (e.g., identify
Chest Ultrasound). causative/precipita-
ting factors.
(Nurse’s Pocket
Guide, 9th ed. by
Doenges,
Marilynn, et.al., p.
70)
XI. NURSING CARE
PLANS