ACTUAL NCP-1

ASSESSMENT EXPLANATION OBJECTIVE NURSING RATIONALE EVALUATION

OF THE INTERVETION
PROBLEM
Subjective: The unpleasant feeling After the 15 min of Assess the location,  helps planning optimal pain GOAL MET
of pain is highly nursing intervention the characteristics, onset, management strategies, and to
“She complains of pain subjective in nature patient will be able to : duration, frequency, quality, evaluate client’s cognitive status in After the 15 min of
behind and in front of that may be and severity of pain. relation to the client’s present nursing intervention the
her left ear. She is experienced by the  . Recognize pain condition patient was
exhibiting unilateral patient. pain is “an onset and causal factors
facial paralysis.”  Acknowledge able to:
unpleasant sensory and
emotional experience the non-  Recognize pain
Objective: -pharmacological method  To determine changes in
associated with actual these vital signs often indicate acute onset and describe causal
 left eye is or potential tissue to reduce the pain factors associated with
Assess and monitor vital pain and discomfort
drooping damage, or described her pain
 inability to in terms of such signs, noting tachycardia,  Verbalize the
raise her eye damage After the 1 hour of hypertension, and increased non- -pharmacological
 puff out her nursing intervention the respiration  To enhance awareness of method to reduce the
cheeks patient will be able to: the client pain
regarding her
BP: 148/60  interventions, Assist the client and provide present condition
GOAL MET
the client will report pain information
T: 36. relieved or controlled regarding present new After the 1 hour of
PR: 83  Verbalize condition and risk that  This clams & soothes the nursing intervention the
feeling of less pain and accompany it patient patient was able to:
RR: 26 discomfort
Provide comfort measures  Demonstrate
NURSING such as deep breathing less feeling of pain
DIAGNOSIS exercises  Verbalize
feeling of less pain and
Acute pain R/T facial  To promote pain relive
discomfort
muscle weakness or
paralysis Administer pain reliever
medication as prescribed

 To protecting the eye from

Provide eye care & Apply dryness and promote comfortable
eye ointment to keep eyelids
closed, an  to stretch and mobilize
ACTUAL NCP-1

facial muscles until the nerve has

repaired itself. It is important to
Educate pt. how to perform promote circulation which will
facial massage gently encourage nerve repair

 help in reducing symptoms

Instruct patient to chew on

the unaffected side of his
mouth and diet rich in
vitamins and minerals,
Eliminate hot fluids and
foods.