Cues Explanation of Goals and objectives Nursing Interventions Rationale Evaluation

the problem
Pain is a LTO: Diagnostic:  The long term
Subjective: typical After 72 hours of nursing  Assess for pain  Reports of pain goal is FULLY
- Rates pain as unpleasant interventions, the patient using a scale from from the patient is MET if the patient
7/10 localized in experience that will be able to: 0 (no pain) to 10 the most reliable has a pain rating
the lumbar area is response a) Describe (severe pain) way of helping the of less than 4,
- Verbalized, from noxious satisfactory pain along with the nurse developing appears relaxed,
“Masakit ang stimuli or control at a level PQRST. optimal pain has an improved
likod ko” actual tissue of less than 4 out management mood and way of
Objective: damage. In this of 10 in the rating strategies coping. The short
- S/P case, a surgical scale. term goal is fully
Laminectomy: manipulation b) Displays  Sudden change in met if the patient
- Flat on bed, was done on improvement in  Monitor vital vital signs may is able to properly
NPO including the L4 and L5 mood and coping signs q 4 hours reflect pain being demonstrate most
medications of the spinal c) Appear more experienced by taught relaxation
- With medication column of the the patient techniques and
relaxed
order of patient because (Increased BP, pain management
Celecoxib 200 of Lumbar PR, RR) skills, and is able
STO:
mg BID for pain stenosis. to respond
After 5 hours of nursing
- Ongoing side Naturally, post-  Suggests positively to the
interventions, the patient
drip of Tramadol operative pain complications different
will be able to:
400 mg to run is present due  Assess for return (collapsing of disc pharmacologic
to the surgical a) Demonstrate the of radicular pain space, shifting of and non-
for 24 hours use of relaxation
- Grimacing noted incision made bone graft) pharmacologic
on the lumbar techniques for requiring further interventions.
when speaking pain management
area and the medical
about pain b) Demonstrate
installation of evaluation and  The long term
internal devices proper positioning intervention.  goal is
to the spine for alleviating PARTIALLY
which is pain  This NSAID MET if the patient
perceived as c) Verbalize pain Therapeutic: works as a cox-2 has a pain rating
foreign by the relief with the  Administer pain inhibitor which of 5-6, appears
body. The non- relief medication blocks the mostly relaxed
onset of this pharmacologic Celecoxib 200mg production of with a few
acute pain and BID as prescribed PEG2 which is complaints. The
makes the pharmacologic by the physician responsible for short term goal is
patient aware interventions pain and partially met if the
that there is the inflammation. patient is able to
presence of an properly
injury, hence  Assist the patient  Readjustment of demonstrate some
Nursing Dx:
allowing to a comfortable position according taught relaxation
Acute pain related to
him/her to seek position by to patient’s techniques and
surgical manipulation
support, elevating the head comfort aids in pain management
(Laminectomy) as
assistance, and of the bed relieving muscle skills. The goal is
manifested by reports
relief. fatigue and also partially met
of pain on the lumbar
discomfort. This if the patient is
area rated as 7/10
also avoids simply compliant