Cues Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: Acute pain r/t surgical After 8 hours of nursing  Acknowledge the pain  Reduces defensive After 8 hours of nursing
incision interventions, pt will be experience and responses, promotes interventions, pt
"Sobrang sakit ng tahi able to report pain is convey acceptance of trust, and enhances reported pain is
ko." as verbalized by the controlled with a pain client's response to cooperation with controlled with a pain
patient. scale of 3/10 from 8/10. pain. regimen. scale of 3/10 from 8/10.
 Monitor vital signs   the trend and
hourly. changes of these
P/S = 8/10  Provide measurements more
nonpharmacological accurately reflect the
pain management patient's ongoing
such as quiet condition.
Objective:
environment, back  pain may respond to
rub, change of non-pharmacological
position, use of cold pain management.
 guarding behavior compress, guided  to relieve, control or
imagery, and watch maintain "acceptable"
 facial grimace
television or radio. level of pain.
 crying  Administer  to permit patient to
analgesics, as administer own IV
 profuse sweating indicated, to pain medication or
maximum dosage, as bolus additional dose
needed. when on continual
Vital signs  Demonstrate and basis drip.
monitor use of self-  reduce occurrence of
administration/PCA muscle tension or
that involves client in spasms or undue
PR: 107 bpm
plan. stress on incision.
RR: 23 bpm  Encourage patient to  to prevent fatigue that
splint the thoracic can impair ability to
BP: 130/90 mmHg incision site during manage or cope with
cough. pain.
T: 36.5 °C
 Encourage adequate
rest periods and
resting between
activities.