ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Acute pain Short term: INDEPENDENT Short term:

related to
- Patient came physical After 3 - 4 Assess and monitor For baseline data After 3 - 4
back after 2 injury agent hours the vital signs hours the
days with as patient will be patient was
complaints of able to: Evaluate pain able to:
evidenced For baseline data
pain in his characteristics and
by client’s
shoulder -Report intensity. (Use pain -Report
complaints
decrease rating) decrease
of pain in
Objective: feeling of pain feeling of pain
his shoulder Document and
- Nurse noted and feeling Long term: investigate changes To demonstrate Long term:
puncture pain upon from previous improvement in
marks palpation Within the reports and evaluate Within the
status or to identify
reminiscent of hospital stay results of pain hospital stay
worsening of
a dog bite on the patient will interventions the patient
underlying
his right be able to: was able to:
condition/developing
shoulder upon Provide or promote
- Verbalize complications - Verbalize
inspection nonpharmacological
understanding pain management: understanding
- Nurse also of causative of causative
noted factors and - Calm activities & factors and
excoriation, purpose of breathing technique purpose of
piloerection, individual individual
therapeutic -Avoid strenous therapeutic
and pain upon
interventions activities such as interventions
palpation
and lifting heavy, cycling, and
-To reduce stress and
medications etc. medications
promote comfort

-Report pain is -To promote rest and -Report pain is

relieved or decrease muscle relieved or
- Encourage
controlled tension or undue controlled
adequate rest
periods stress in right
shoulder

-To prevent fatigue

DEPENDENT that can impair ability
to manage or cope
Administer
with pain.
vaccination regimen
for 7 days for
category III exposure
(PVRV 0.5 mL IM & This is given as part of
HRIG 20 IU/kg) the protocol of the
DOH for exposures

COLLABORATIVE:
Coordinate with the
officials of the
barangay where the
patient was bitten in.

For them to be aware

of the situation and
for them to be able to
Coordinate with the take action to ensure
health officials of the that the problem
said baranggay does not worsen

Coordinate To figure out how to

with the local animal secure the health of
control officials members of the
community

To assess the
situation regarding
the animals and to
figure how to take
further action to
prevent reoccurrence