Problem Scientific Basis Goals/Objective

Criteria
Nursing
Intervention
Rationale Evaluation
S:
medyo sakit
gamay sa akong
lubot banda as
verbalized by the
patient

O:
> Pain scale 2/10
> Facial grimace
upon movement
> RR: 25cpm


A:
Acute pain related
to rectal
adenocarcinoma

Unrelieved
acute preoperative
pain leads to
development
of chronic pain
syndromes and
increased
complications.In
fact,unrelieved pain
can kill.

After 8 hours of nursing
interventions, the
Patient:
will be able to
experience
gradual
reduction/relief
of
Pain

will have
normal
respiratory
rate
has no facial
grimace upon
movements


INDEPENDENT:

1 . I n s t r u c t
c l i e n t t o
report any
improvement/exace
rbation in pain
experience
2.E n c o u r a g
e verbalization
of feelings about
the pain




3.Pr o v i d e
c o mf o r t
measures such as
use of incentive
spirometry or
blow bottles.
>Un r e l i e v e d
p a i n can create
other problems such
as anger,
anxiety,immobility,res
piratory problems,
and delay in healing.(

> On l y t h e
c l i e n t c a n judge
the level and
distress of
pain; pain
management should
be a team approach
that includes the
client.Very few people
lie about
pain.(Medical-
Surgical Nursing,
7 th ed. by Black,
Joyce
M.andJane Hokan
son Hawkspg.443)

Goal was
partially met
as
evidenced
by the
patient
reduction of
pain in few
hours.

4 . E n c o u r a
g e relatives
to perform touch
therapy

5.En c o u r a g e
a n d assist client
to do deep
breathing
exercises
6. Give pain
medications
PRN


Dependent:
1.Tell the
attending
physician if pain
still persist.


> T o
p r o v i d e nonphar
macologic pain
management.
(Nurses
Pocket Guide, 9th
ed.by Doenges,Ma
rilynn, et.al.,
p.368)

> T h e
h u ma n b o d y is
believed to have
energy fields that
express
aberrant patterns
when body systems
arei
nsulted.Therapeutic
Touch is thought
torealign aberrant
fields. (Medical-
Surgical Nursing,7
Th ed. by
Black, Joyce M.
andJane Hokanso
n Hawks; p. 480)
Source: Nurses Pocket Guide 11
th
Edition, Medical Surgical Nursing 7
th
edition





>Deep br eat hi
ng f or relaxation is
easy to learn and
contributes to pain
relief and/or reduction
by reducing muscle
tension and anxiety.
(Medical surgical
nursing 7
th
ed. By
Balck Joyce and
Hokanson Hanwks
pp. 449)

>to decrease the pain
felt by the patient

>to administer
immediate response
to the health status of
the patient.
Problem Scientific Basis Goals/Objective
Criteria
Nursing
Intervention
Rationale Evaluation

Problem Scientific Basis Goals/Objective
Criteria
Nursing
Intervention
Rationale Evaluation
Objective cues:
excessiv
esweating