ASSESSMENT DIAGNOSIS BACKGROUND PLANNING INTERVENTION RATIONALE EVALUATION

KNOWLEDGE
SUBJECTIVE: Acute pain Inflammed spinal After 1-2 hours 1. Monitored vital signs 1) For baseline After 1-2 hours
related to cord of nursing changes of nursing
“Masakit yung leeg disease process intervention intervention the
ko, parang hindi ko as evidence by patient’s 2. Encouraged deep 2) To help the patient
maigalaw at parang limited complain of breathing exercises as a patient to verbalized that
mainit kapag capacity to Neural pathways pain of 7/10 relaxation technique. relaxed the pain is
hinahawakan” perform disturbances decrease to a leesened to a
  movements mild and manageable
Objectives: manageable 3. Placed the patient in scale of 3/10.
Facial grimace Sensory fibers scale. comfortable position 3) To promote
Self-guarding dysfuntion ( High fowlers) comfort and also GOAL MET
Pain scale of 7/10 . ensure good
  circulation
Vital Signs:
BP 130/90
T: 35.2 4. Administered 4) To lessen
PR: 86 False medication as as per patient’s pain
RR:22 interpretation of Doctor’s order
any stimulants as
burning pain 5. Celocoxib 200mg 1tab
PRN 5) To reduce
possible
inflammation
and pain
6. Pregabalin 75mg 1tab
OD 6) To treat
neuropathic pain
7. Applied Ice collar
7) To alleviate pain
or to promote
healing