CUES

NURSING DIAGNOSIS
Acute pain r/t disease process as evidenced by nonverbal cues such as (+) guarding and facial grimace. STG:

GOAL

NURSING INTERVENTION

RATIONALE

EVALUATION

Subjective: ³Masakit talaga µtong nararamdaman ko´, as verbalized by the patient. - 1 is the lowest and 10 is the highest pain scale; Pain scale is 6/10 Objective: V/S: T= 37.5 °C PR= 82 bpm RR= 24 cpm BP= 130/90 mmHg

After 4 hours of proper nursing intervention the patient reports that the pain is relieved/ controlled.

Independent: y Monitor skin y To provide baseline color/temperature data and usually and vital signs. altered in acute pain. y Perform a y To rule out comprehensive worsening of assessment of underlying pain to include condition/developme location, nt of complications. characteristics, And in order to plan onset, duration, effective treatment. frequency, quality, intensity or severity, and precipitating factors of pain. Note changes. y Pain is a subjective y Encourage experience and verbalization of cannot be felt by feelings about the others. pain. y Pain is subjective y Accept client¶s experience and description of pain. Acknowledge cannot be felt by others. the pain experience and convey acceptance of

GOAL MET

y

y Guarding behavior, protecting body part y (+)Facial grimace y (+)Irritability

client¶s response to pain. Moorhouse and A.498-503 . maximum dosage. y To promote nonpharmacological pain management and to distract attention and reduce tension. y Provide comfort measure. y Encourage adequate rest periods. y To prevent fatigue. MF. Murr p. 11th ed. repositioning. as needed. to pain. Doenges. encourage use of relaxation techniques such as touch. Source: Nurse¶s Pocket Guide. nurse¶s presence and deep breathing and encourage use of diversional activities such as socialization with others. by M. Dependent: y Administer y To maintain analgesics. as acceptable level of indicated.

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