Assessment

SUBJECTIVE:
kung mangihi ko
day, sakit man as
verbalized by the
patient.

Objective:
Facial grimace.
Restlessness.
V/S taken as
follows:
T: 37.3
P: 82
R: 19
BP: 120/90

Diagnosis
Acute pain
related to
biological
factors such as
trauma or
activity of
disease
process

Planning
After 8 hours of
nursing
interventions, the
patients pain
will be
relieved or
controlled.

Intervention

Rationale

Independent:
Assess pain,
noting location,
intensity (scale
of
0 10),
duration.

Provides
information to
aid in
determining
choice or
effectiveness of
interventions.

Encourage
increased fluid
intake.

Increased
hydration
flushes bacteria
and toxins.

Investigate
report
of bladder
fullness.

Urinary
retention may
develop,
causing tissue
distention (
bladder or
kidney), and
potentiates risk
for further
infection.

Observe for
changes in
mental status,
behavior or level
of
consciousness.

Accumulation of
uremic waste
and electrolyte
imbalances
may be toxic to
the CNS.

Evaluation
After 8 hours
of nursing
interventions, the
patients pain
will be
relieved or
controlled.

 Provide comfort
measure like back
rub, helping
patient assume
position of comfort.
Suggest use of
relaxation
technique and
deep breathing
exercises.

Encourage use
Of sitz baths, warm
soaks to the
perineum.

Collaborative:
Administer
antibacterial as
prescribed

Promotes
relaxation,
refocuses
attention, and may
enhance
coping abilities.

Promotes
muscle
relaxation.

Reduces
bacteria present
in urinary tract
and those
introduced by
drainage
system