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  • Assessment Diagnosis Inference Planning Nursing Intervention Rationale Subjective: "Palaging Sumasakit Ang Independent

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    >Assist with ambulation as needed. >Promotes circulation, prevents complications of immobility and promotes comfort. >Provide comfort measures e.g. back rub, warm compress. >Promotes relaxation, comfort and relieves pain. >Monitor and document response to interventions. >To evaluate effectiveness of interventions and modify plan of care accordingly. >Report changes in condition to physician. >To ensure client receives appropriate treatment and care. >Provide health teaching regarding disease process, treatment, pain management and self-care. >Promotes understanding, adherence to treatment and self-management.

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    >Assist with ambulation as needed. >Promotes circulation, prevents complications of immobility and promotes comfort. >Provide comfort measures e.g. back rub, warm compress. >Promotes relaxation, comfort and relieves pain. >Monitor and document response to interventions. >To evaluate effectiveness of interventions and modify plan of care accordingly. >Report changes in condition to physician. >To ensure client receives appropriate treatment and care. >Provide health teaching regarding disease process, treatment, pain management and self-care. >Promotes understanding, adherence to treatment and self-management.

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    29 views2 pages

    Assessment Diagnosis Inference Planning Nursing Intervention Rationale Subjective: "Palaging Sumasakit Ang Independent

    Uploaded by

    Anna Caronan
    >Assist with ambulation as needed. >Promotes circulation, prevents complications of immobility and promotes comfort. >Provide comfort measures e.g. back rub, warm compress. >Promotes relaxation, comfort and relieves pain. >Monitor and document response to interventions. >To evaluate effectiveness of interventions and modify plan of care accordingly. >Report changes in condition to physician. >To ensure client receives appropriate treatment and care. >Provide health teaching regarding disease process, treatment, pain management and self-care. >Promotes understanding, adherence to treatment and self-management.

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    ASSESSMENT SUBJECTIVE: Palaging sumasakit ang tagiliran ko, as verbalized by the client OBJECTIVE: >irritated >anxious > facial

    grimace >body malaise and fatigue >diaphoresis >pallor >Painscale of 6 out of 10, 10 being the highest

    DIAGNOSIS

    INFERENCE

    PLANNING After 30minutes to 1 hour of nursing intervention the clients painscale will decreases from 8/10 to 3/10.

    Acute Pain related to Tissue damage detect by acute renal inflammatory sensory neurons process Tissue injury Stimuli Noxious stimuli trigger release of biochemical mediators(e.g. prostaglandins, histamine,bradykinin) Inflammation sensitization of nocireceptors transmits pain sensation Response(pain perceived sympathetic nervous system response: PR,RR,BP

    NURSING INTERVENTION Independent: >Assess pain, including location, quality, duration and intensity.

    RATIONALE

    >To know the severity , development and progression of pain and disease and to obtain baseline data and compared with the clients previous pain symptoms. >Non verbal cues may be both physiologic and psychologic and maybe used in conjunction with verbal cues to evaluate extent/severity of the problem.

    >Assess nonverbal cues.e.g. abdominal guarding, tachycardia, diaphoresis.

    Diaphoresis Dilated pupils >facial mask of pain (facial grimace) >restless, irritated and anxious

    >Assess and review factors that aggravate or alleviate pain.

    >Helpful in establishing diagnosis and treatment needs.

    >Monitor urine output to changes in color, odor and voiding pattern, input and output every 8 hours and monitor

    >To identify indications of progress or deviations from expected results.

    the results of repeated urinalysis.

    > Provide nonstimulating, calm and quiet environment and encourage client the use of relaxation technique e.g. music therapy.

    >Reduction of anxiety, tension that can promote relaxation and comfort and distract attention of the client of pain. >Helps to redirect attention and for muscle relaxation.

    >Help or encourage the use of focused relaxation breathing.

    >To conserve and restore energy >Encourage client to rest. >Relieves pain, promotes general comfort and rest.

    Dependent: >Administer medications as indicated e.g analgesics and antibiotics.

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