ASSESSMENT DIAGNOSIS OUTCOME PLANNING INTERVENTION EVALUATION

IDENTIFICATION
Subjective Data: Acute pain related to Patient will be able to At the end of 1-2 INDEPENDENT: The goal was partially
“ masakit ang mga kasu- muscle stiffness all displays improved days of nursing -Provide rest periods to promote met. The was able to
kasuan ko” as verbalized over the body well-being, relaxed intervention the relief, sleep, and relaxation report pain scale of 5/10
by the patient muscle tone or patient will be R: Pain may result in fatigue, which from 7/10.
Pain Scale:7/10 body posture. able to describes may result in exaggerated pain.
satisfactory pain
control at a level - Get rid of additional stressors or sources
Objective Data: less than 3 to 4 on of discomfort whenever possible.
-Facial mask of pain a rating scale of 0 R: Patients may experience an
-restlessness to 10 and displays exaggeration in pain to tolerate painful
-irritability improvement in stimuli if environmental,
mood, coping. intrapersonal, or intrapsychic factors
are further stressing them.

-Cognitive-behavioral strategies such as

Imagery and relaxation exercises,
biofeedback, breathing exercises, music
therapy
R: The aim of these techniques is to
lessen the stress, tension,
subsequently decreasing the pain.

- Apply warm or cold compress

alternatively
R: Heat decreases pain
through improved blood blow to the
area and through reduction of pain
reflexes. Cold lessens pain and muscle
spasticity by decreasing the release of
pain-inducing chemicals.

DEPENDENT:
-Administration of NSAIDS as ordered.
R: They are effective in managing mild
to moderate pain.