DATA ANALYSIS

Supporting data
Ds: the patient says pain when urinating
P: when urinating
Q: like burned
R: lower abdomen
S: pain scale 4
Q: missing appears
Do: general condition is weak
the patient looked grimace
warm accral
diaphoresis –
Problem
Acute pain
Causes
Microorganism → enter the urinary track → bladder → inflammation → tissue swelling →pain
when urinating → acute pain
Nursing diagnoses
Acute pain is related with physiological agents
Nursing Action Plan
Nursing Diagnoses : Acute pain is related with physiological agents
Goal Criteria
after nursing action for 2x24 hours acute pain can be reduced or lost with the results criteria:
1. shows a decrease in the intensity of the pain scale
2. able to control pain (knowing the cause of pain)
3. expressing comfort after reduced pain
Nursing Action
Monitor
1. Assessment pain, record location, and characteristics
2. Observation vital signs
Independent
 1. Greeting and introducing to patient
2. Give warn compresses
Health education
1. Teach relaxation (deep breathing)and distraction techniques
Collaboration
1. Collaborate with medical team in providing analgesic as indicated
Rational
Monitor
1. To find out the patient’s pain condition
2. To know general condition of the patient
Independent
1. To keep interpersonal relationship
2. Warm compress therapy can help reduce pain
Health education
1. Reduce tension and make feel more comfortable
Collaboration
1. To reduce pain and speed healing
IMPLEMENTATION
Action
1. Greeting and introducing to patient
2. Observation vital signs and general condition patient
3. Assessment pain, record location, and characteristic
4. Teach relaxation technique
5. Collaboration with medical team in providing analgesic
Response/result
1. Patient and family are cooperative
2. General condition
BP : 100/60mmHg Temperature : 38,30C
Pulse : 60×/minute RR : 20×minute
3. P : when urinating
Q : like burned
 R : lower abdomen
S:4
T : missing appear
4. Patient can follow the instructions and practice by self
5. Patient receive ketorolac injection 30mg