Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Acute Pain related Short Term Independent Goal Met.

Client reports of to disease process Goal - Assess the level of - Knowing the level of After 4 hours of
abdominal pain as evidenced by After 4 hours pain, location and pain that is felt so it nursing
client reports of of nursing scale of pain, can help determine intervention,
abdominal pain and intervention, perceived client. appropriate the client
Objective: non-verbal cues the client will interventions. reports that
- Guarding such as (+) report that pain is relieved
behavior, guarding behavior, pain is - Observation of vital - Changes in vital and controlled.
protecting body facial grimace and relieved and signs every 8 hours. signs, especially
part irritability. controlled. temperature and
- (+) facial pulse rate is one
grimace indication of
- (+) irritability increased pain
experienced by the
Pain scale of 5/10 client.

Vital Signs taken as - Instruct client to - Relaxation

follows: perform relaxation techniques can
BP=120/90 techniques make the client feel
T=36.9 comfortable and a
P=85 little distraction to
R=20 divert the attention of
clients to pain so
that they can help
children reduce the
pain.

- Provide a comfortable - a comfortable

position. position to avoid an
emphasis on the
area of injury pain.
Collabrative:
- Administer analgesic
as ordered - Analgesic drugs
block the pain
receptors so that the
pain cannot be
perceived.