ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Acute pain related to Short Term Goal: Dependent:

“Masakit ang tahi ko” as tissue injury secondary After 1 hour of nursing  Administer Tramadol,  Pharmacologic After 1 hour of nursing
verbalized by the client. to surgical incision; intervention the client will as ordered. treatment to intervention the client
Caesarian Section reported pain is controlled
be able to report pain is relieved pain.
Pain Scale: 8/10 with pain scale of 3/10.
relieved. Independent:
 Provide calm quiet
OBJECTIVE:  To avoid stress in
environment
- Facial grimace patient that may
- Guarding behavior worsen pain.
Long Term Goal  Instruct deep After 24 hours of
- Restlessness
After 24 hours of nursing breathing exercises continuous nursing
Vital signs taken:  Non-pharamacologic
intervention the client will intervention the client was
T: 36.2 measures that
be able to demonstrate able to manage pain.
P: 83 provides relief of
R: 20 ways on how to manage pain.
BP: 150/90 pain.  Encourage
diversional activities
(e.g. listening to  Increases release of
music) endorphins and
enhance the
therapeutic effects of
pain management
program.
 Encourage adequate  Promotes a relaxed
rest periods. feeling to the
patient.