ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS
SUBJECTIVE Acute Pain R/T Short-term Goal: Independent: GOAL MET
CUES: Decreased Cerebral
After 4 hours of  Assess contributing  To determine Short-term Goal:
Blood Flow Secondary to nursing interventions,
“I still feel like my factors to pain (noise, underlying cause of
Physical Trauma as the patient will be able After 4 hours of
head is being banged wrong positioning, pain and treat
Manifested by Guarding to become relieved of nursing interventions,
on a wall.” As environment) accordingly.
Behavior, Facial Grimace signs and symptoms of the patient verbalized
verbalized by the “I feel better. It’s just
and Pallor pain experienced as
patient. a little sore from all
evidenced by  Certain drugs may
verbalization of pain is  Review medication the swelling. But it is
cause fatigue and
relieved (rate pain from regimen tolerable pain.” rated
drowsiness.
OBJECTIVE 0-4 out of 10) pain as 4 out of 10.
CUES:
 Rated pain as 9  Ask client to rate pain  To assist in evaluating
Long-term Goal: impact of pain on Long-term Goal:
out of 10 on 0-10 scale (rated as
client’s life.
 Facial grimace After 8 hours of 9 out of 10) After 8 hours of
 Guarding nursing interventions, nursing interventions,
behavior the patient will be able  To allow the patient was able to
(clutches head to Rest and feel rested  Provide comfort nonpharmacological relax by utilizing bed
and assumes after adequate rest measures such as pain relief and rest and deep
fetal position) interval and Utilize promote good breathing, and was
repositioning the client
 Palmar and non-pharmacological circulation to the brain able to sleep for 6
in a comfortable
facial pallor. methods of pain relief and decrease hours straight and felt
position and providing
 Temp: 37.2 (deep breathing, guided vasoconstriction
a hot or cold compress rested afterwards.
 PR: 86 bpm imagery, etc.)
 RR: 22 cpm
 BP: 130/90
mmHg  Provide calm and  To decrease
quiet environment environmental factors
(adjust lights, which contribute to
temperature and migraine and promote
eliminate offensive rest.
 odors which may
contribute to
 To distract attention
headache)
from pain and
 Instruct in relaxation decrease tension
techniques (deep
breathing, imagery)

 To conserve energy of
 Encourage adequate the patient and prevent
rest periods fatigue

 To promote client
 Assist in self-care independence as much
activities as tolerated as possible and
acquire sense of
function

 To enhance quality
 Provide peaceful\and sleep and promote rest
adequate resting which harnesses
environment (dim energy for future use.
lights, adjust
temperature, wrinkle-
free bed, quiet
surroundings)
Collaborative:
 Medications will
 Administer medications provide synergistic
as ordered by physician effect with
(analgesics, etc.) nonpharmacologic
interventions for pain
relief and promote
better circulation by
aiding in vasodilation
for better blood flow
 to the brain and
altering prostaglandin
synthesis to decrease
pain.

 The significant others

know the client more
 Encourage watchers to and will be able to aid
assist patient during in diverting client’s
diversional activities attention from pain.
(minimize noise, allow
client to verbalize
feelings and promote
rest and sleep)