ASSESSMENT DIAGNOSIS PATTERN PLANNING INTERVENTION EVALUATION

Date: August 11, Acute pain S Within the shift, Independent Date: August 11,
2021 related to loss of E the patient pain 1.Assess the 2021
Time: 3:00pm blood supply to N scale will location, Time: 6:00pm
the occipital S decrease from frequency and
Subjective Data: cortex associated A 7/10 to 6/10 duration of pain “GOAL MET”
• “Sakit ang likod with increased T R: Indicates need After 8 hours of
sakong liog intraocular I for effectiveness nursing
nurse” as pressure O of intervention interventions
verbalized by the N and may signal patient verbalized
patient. A development decreased of

Rationale: An L resolution of pain scale from

Objective Data: increase in / complications 7/10 to 6/10
● Pain intracranial P 2. Monitor vital
scale of pressure (ICP) is E signs
7/10 the result of the R R: Vital signs are

● VS amount of brain C baseline datas to

BP: tissue, blood, and E know if there is

cerebrospinal P an acute illness

PR:
fluid (CSF) within T to the patient.
RR:
the skull at any I 3. Encourage
T:
one time. O diversional
● + facial
Elevated ICP N activities and
grimace
may be seen relaxation
● +
secondary to techniques
guarding
brain tumors, R: to distract atte
behavior
subarachnoid and reduce
● Administ tension
hemorrhage, and
ered 4. Provide
toxic and viral
paraceta comfort
encephalopathies
mol . measures,quiet
500mg environment and
PRN calm activities
● R: to promote
non
pharmacological
pain
management
5. Refer to ROD
and administer
paracetamol
500mg PRN
6. Explain to
patient and
significant others
about the disease
process