Assessment Diagnosis Planning Intervention Rationale Evaluation

SUBJECTIVE: Acute pain After 8 hours of Independent: After 8 hours

related to nursing of nursing
“kung mangihi ko biological interventions, the · Assess pain, · Provides interventions, the
day, sakit man” as factors such as patient’s pain noting location, information to patient’s pain
verbalized by the trauma or will be intensity (scale aid in will be
patient. activity of relieved or of determining relieved or
disease controlled. 0 – 10), choice or controlled.
process duration. effectiveness of
Objective: interventions.
· Facial grimace.
· Restlessness. · Encourage · Increased
· V/S taken as increased fluid hydration
follows: intake. flushes bacteria
T: 37.3 and toxins.
P: 82
R: 19 · Investigate · Urinary
BP: 120/90 report retention may
of bladder develop,
fullness. causing tissue
distention (
bladder or
kidney), and
potentiates risk
for further
infection.

· Observe for · Accumulation of

changes in uremic waste
mental status, and electrolyte
behavior or level imbalances
of may be toxic to
consciousness. the CNS.
· Provide comfort · Promotes
measure like back relaxation,
rub, helping patient refocuses
assume attention, and may
position of enhance
comfort. coping abilities.
Suggest use of
relaxation
technique and deep
breathing
exercises.

· Encourage use · Promotes

Of sitz baths, warm muscle
soaks to the relaxation.
perineum.

Collaborative:
· Administer · Reduces
antibacterial as bacteria present
prescribed in urinary tract
and those
introduced by
drainage
system