Assessment Nursing Diagnosis Scientific Rationale Objectives Nursing Responsibilities Rationale Evaluation

SUBJECTIVE: Acute Pain related to As inflammation SHORT TERM: SHORT TERM:

“Masakit it akon tiil tissue trauma as occurs, chemical Within 15 min. of Within 15 min. of
asya diri ako evidenced by reports mediators such as nursing nursing
nakakalakat.” as of pain and guarding prostaglandins are interventions, client interventions, client
verbalized by the behavior. released from will be able to: was able to:
patient. damaged cells.
Local cytokine and a. Verbalize gradual INDEPENDENT: a. Verbalize gradual
“Bisan ginkakaptan keratinocyte reduction of pain. 1. Assess degree and 1. Degree of pain is directly reduction of pain.
la, mas naduory it production characteristics of discomfort related to inflammatory
sakit” as verbalized contributes to the and pain. process.
by the patient. painful sensation.
2. Assess pain reports, noting 2. Indicates need for, and
Source: location, intensity (0–10 or effectiveness of,
OBJECTIVE: Principles of similar coded scale), interventions and may
Pain rating scale of Pathophysiology - frequency, and time of onset. signal development or
7 out of 10. 10 being Bullock, Shane. Note nonverbal cues, such as resolution of complications.
the most painful and LONG TERM: restlessness, tachycardia, or LONG TERM:
0 being the least. Within 1 month of grimacing. Goal met.
nursing “Nawara naman an
Vital signs: interventions, 3. Assist client to quantify 3. Provides baseline for sakit. Gintagaan
PR: 98bpm patient will be free pain by comparing it to other comparison to aid in man liwat ako han
RR: 18cpm of pain. experiences. determining effectiveness of reseta pag-uli ko” –
Temp: 37.6C therapy, resolution, or as verbalized by
progression of problem. patient
Patient cannot
manage to walk. 4. Monitor vital signs, noting 4. Elevations in heart rate
elevated temperature, heart may indicate increased
Patient has necrosis rate, and blood pressure. discomfort or may occur in
in right ankle. response to fever and
inflammatory process. Fever
Patient tries to move Nurse's Pocket can also increase client’s
her leg when Guide - Doenges, discomfort.
someone is trying to Marilynn E.
hold/touch it. 5. Review factors that 5. Helpful in establishing
aggravate or alleviate pain. treatment needs.
 6. Encourage client to report 6. Efficacy of comfort
pain as it develops rather than measures and medications is
waiting until level is severe. improved with timely
intervention.

7. Encourage verbalization of 7. Can reduce anxiety and

feelings. fear and thereby reduce
perception of intensity of
pain.

8. Instruct client in, and 8. Promotes relaxation and

encourage use of non- feeling of well-being.
pharmacological pain reief Provides a sense of having
techniques such as: some control over the
visualization, guided imagery, situation.
progressive relaxation, deep-
breathing techniques,
meditation, and mindfulness.

COLLABORATIVE:
9. Administer medications as 9. Provides relief of pain
ordered. and discomfort.
a. Nalbuphine 5mg IVTT q6h
PRN
b. Celecoxib 200mg/tab, 1 tab
BID
Source: Nursing Care
Plans, Edition 9 - Murr,
Alice, Doenges, Marilynn,
Moorehouse, Mary