___________

Patient’s Name (Initials): ____________________________ Admitting Diagnosis/Medical Diagnosis/CC:_____________________________

Age:___________ __Sex:_____________ Physician (Initials): _______________________
Room No:___________ Diet:____________________________________________

SUBJECTI OBJECTIVE NURSING SCIENTIFIC ANALYSIS PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME
VE DIAGNOSIS

Independent: After 2 hours of

“Sakit  Pt. Acute pain After 2 hours of nursing
kaayo is r/t post nursing 1. Acknowledge 1. Nurses interventions:
akoa restl ORIF Acute pain is a complex interventions: and accept have the
right ess procedure process involving  Pt. will the client’s duty to  Pt. will
leg”, as when a/e by pain activation of report that pain. ask their report that
verbaliz in rating of nociceptors, chemical pain is clients pain is
ed by pain 10/10, 1 relieved or about relieved or
mediators and
the  Facia having no controlled their pain controlled
patient, pain and 10 inflammation. and
l  Follow  Follow
with having the Medications can be used believe
grima prescribed prescribed
pain ce most to target each of the pharmacolog their pharmacolog
rating obser key elements within the ic regimen. reports of ic regimen.
of 10/10 ved pain pathway and pain.
 Verbalize  Verbalize
eliminate or reduce the 2. Determine
non- non-
and document 2. Acute pain
sensation of pain.  pharmacolog pharmacolog
presence of is that
ical ical
possible which
methods methods
pathophy- follows a
that that
Definition: siological trauma, or
provide provide
Pain is an and procedure
relief. relief.
unpleasant psychologica such as
sensory and l causes of surgery,
emotional pain. or occurs
experience suddenly
associated with the
with actual onset of a
or painful
potential condition.
tissue
EVALUATION
damage, or 3. Monitor 3. Vital
described vital signs signs

Proposed By: Mrs. Sharry Mae G. Awayan, RN, MAN

 in terms of including usually
such the skin are  Goals
damage. A color. altered in partially
sudden or acute met.
slow onset 4. Provide pain.
of any with nonpharmacol
any ogic pain 4. These
intensity management. methods
from mild (e.g. are used
to severe distraction; to provide
and with guided comfort by
duration imagery). altering
off less psychologi
than 3 cal
months. 5. Be aware of responses
client`s to pain.
Reference: “right to
Johnson, Q., Borsheski, treatment” 5. Failure to
Reference: that meet the
Deonges, R. R., & Reeves-Viets, includes standard
M.E., prevention of
Moorhouse J. L. (2013). of/or assessing
M.F., & adequate pain can
Murr A.C. A review of management relief from be legally
Copyright pain. interprete
2019 by. of acute pain. Missouri d as
F.A. Davis Medicine, 110(1), 74– 6. Evaluate and nursing
Company. 79. document negligence
Nurse’s https://www.ncbi.nlm.ni client`s .
Pocket h. response to
Guide: gov/pmc/articles/ medication 6. Increasing
Diagnoses, PMC6179627/ given and or
Prioritized assist in decreasing
Interventio transition- dosage,
ns, and ning or helps in
Rationales altering self-
15th drug management
Edition. regimen, of pain.
F.A. Davis based on
Company, individual

Proposed By: Mrs. Sharry Mae G. Awayan, RN, MAN

 Philadelphi needs and
a, protocol.
Pennsylvani
a.
Dependent:

1. Administer
medication, as
indicated, to 1. This is
maximum dosage, done to
as prescribed maintain
by the acceptable
physician. or tolerable
rate of
pain.
Reference:
Deonges, M.E.,
Moorhouse M.F.,
& Murr A.C.
Copyright 2019
by. F.A. Davis
Company.
Nurse’s Pocket
Guide:
Diagnoses,
Prioritized
Interventions,
and Rationales
15th Edition.
F.A. Davis
Company,
Philadelphia,
Pennsylvania.

Proposed By: Mrs. Sharry Mae G. Awayan, RN, MAN