Scientific Implemented

Assessment Diagnosis Planning Selected Intervention Rationale Evaluation

Explanation Intervention
Subjective: Alteration in Unpleasant After 1 day of  Note client’s pain  Noted client’s pain To determine the The patient
 “masakit iyung tuhod comfort; Acute Pain sensory and nursing scale scale level of pain verbalize
koh. Medyo malalim r/t Physical Injury emotional intervention, the  Determined Possible minimized pain
kasi iyung sugat” as experience arising client’s pain scale  Determine Possible cause of pain like and discomfort
verbalized by the from actual or will be able to cause of pain like physical injury and a 4/10 pain
client. potential tissue decrease from 7/10 physical injury  Observed non verbal Observation may/ scale
 Pain Scale of 7/10 damage or to 4/10  Observe non verbal cues of pain like facial may not be
Objective: described in cues of pain like facial grimace congruent with
 (+) Facial Grimace terms of such grimace verbal reports
 (+) Discomfort damage; sudden  Provided comfort  To promote
 (+) restlessness or slow onset of  Provide comfort measures like nonpharmacologic
 (+)guarding behavior any intensity from measures like providing a quiet al pain
 Increase Blood mild to severe providing a quiet environment management
Pressure; 140/90 with an environment  Encouraged  To divert attention
 Dressing on Right Leg anticipated or  Encourage diversional diversional activities to pain
predictable and a activities such as such as listening to
duration of less listening to music and music and reading
than 6 months reading newspaper newspaper
 Encourage  Encourage
verbalization of verbalization of
feelings feelings
 Encourage use of  Encouraged use of  To distract
relaxation techniques relaxation techniques attention and
like focused breathing like focused breathing reduce tension
 Encourage adequate  Encouraged adequate  To prevent fatigue
rest period rest period
 Administer analgesic  Administered  To maintain
as ordered analgesic as ordered acceptable level of
pain
Diagnosis: Multiple Abrasion and Avulsed wound inferogingivolabial Area