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Date/ Cues Need Nursing Diagnosis Objective of Care Nursing Interventions Evaluation

Time
Subjective: Acute pain related to 1. Assess pain characteristics.
07/05/ - “Doc, kani dinhi C inflammation of the That within the 2- ®Assessment of the pain “GOAL MET “
10 ba(holding the right O joints hour span of care, experience, is the first step in
leg, pelvic area) sakit G my patient’s planning pain management @
man kaayo, kaning N ®Inflammation is a comfort condition strategies. 07/05/10
@ bukog-bukog”, I defensive reaction will improve as 12pm
“maglisod ko ug lakaw, T intended to neutralize, evidenced by: 2. Accept client’s description of
10 wala man gud koy I control, or eliminate pain. After 2-hour span of
AM kusog, naunsa naman V the offending agent - decreased pain ®Pain is subjective experience care, the patient’s
ni?” “Dili man ko ing E and to prepare the intensity as 1 in and cannot be felt by others. condition is
ani pag-abot diri”, as site for repair. pain scale improved as
verbalized by the P Regardless of the - no grimaced face 3. Respond immediately to evidenced by:
patient. E cause, a general noted complaint of pain
R sequence of events - no withdrawal ®Prompt responses to complaints - pain scale of 1
- rated the intensity of C occurs in the local when there is may result in decrease anxiety in - grimaced face not
pain as 7 in the pain P inflammatory physical contact the patient. Demonstrated noted
scale of: T response. This with the joint concern for the patient’s welfare - no withdrawal
1 - no pain U sequence involves - verbalization of and comfort fosters the when there is
2 less A changes in the feeling of comfort development of a trusting physical contact
3 pain L microcirculation, relationship. with the joint
4 slightly moderate including vasodilation, - “di naman sakit
5 pain P increased vascular 4. Instruct the patient to report akong mga joints
6 A permeability, and pain. karon(holding the
7 moderate pain T leukocytic cellular ®Relief measures may be right leg)”, as
8 T infiltration. As these instituted verbalized by the
9 severe E changes take place, . patient.
10 pain R five cardinal signs of 5. Position the patient
N inflammation are comfortably on bed.
Objective: produced: redness, ®Comfortable position will aid in
- Grimaced face noted heat swelling, pain, relaxing the muscle and it will
- Withdrawal with and loss of function. help to lessen the pain.
physical contact with
the joint 6. Administer analgesic drug.
- with medication of ®Analgesic drug help relieve and
Norgesic forte manage painful joints.

7. Provide cold compress to the


patient.
®Cold compress may reduce
total edema and may promote
some numbing, thereby
promoting comfort
.
8. Encourage to use relaxation
techniques (e.g. deep breathing
exercise).
®Relieve muscle tension and
may improve coping abilities.

9. Provide anticipatory
instruction on pain causes,
appropriate prevention, and relief
measures.
®Knowledge about what to
expect can help the patient
develop effective coping
strategies for pain management.

10. Instruct the patient to


evaluate and report effectiveness
of measures used.
®Pain relief strategies can be
modified to promote more
satisfactory comfort levels.

11. Render health teachings


such as enough rest and sleep.
®Health teachings will lead
proper health status.