NURSING

CUES SCIENTIFIC BASIS OBJECTIVES IMPLEMENTATION RATIONALE EVALUATION

DIAGNOSIS

SUBJECTIVE: Acute pain A person with cancer Short Term: Independent: Independent: Short Term:
“Dida han May related to soft often experiences After 4-6 hours of 1. Assess pain 1. Assessment of pain After 4-6 hours of
9 han tissue pain and discomfort nursing interventions characteristics: experience is the first nursing interventions
naglalaba ako, sarcoma on for numerous reasons. the patient will be able a. Quality (e.g., burning, step in planning pain the patient was able
pagsurayi ko his left thigh Tumors cause pain by to: sharp, shooting) management to:
pagbuhat, and calf invading, destroying b. Severity (scale of 0 or strategies. The most
secondary to or compressing the  Demonstrate use  Demonstrate
waray ko of relaxation skills no pain to 10 or most reliable source of use of relaxation
kayani kay pathologic affected area. severe pain information about the
fracture. Common causes of and diversional skills and
masakit hin activities such as c. Location (anatomical pain is the patient. diversional
duro. Hasta pain in cancer patients description)
by tumor are: deep breathing activities such
yana masakit la exercises. d. Onset (gradual or as deep
gihap labi na  Release of pain- sudden) breathing
 Report pain is
kun causing substances e. Duration (how long; exercises.
controlled or
guinsasabod o produced by the intermittent or
relieved with a  Report pain is
guin-gagalaw,” tumor or by the continuous)
scale of 3/10 from controlled or
as verbalized immune system in f. Precipitating or
6/10. relieved with a
by the client. response to the relieving factors
 Have vital signs scale of 3/10
Client rated presence of tumor 2. Observe nonverbal 2. Observations may be
within normal from 6/10.
pain as 6/10  Invasion of tumor in cues/pain behaviors and not congruent with
range.  Have vital signs
with 1 being bones, nerves, other objective cues verbal reports.
as follows: HR –
the lowest and pleura/peritoneum, defining characteristics, as
89 bpm; RR –
10 being the viscera, blood noted, especially in
18 cpm; BP –
highest. vessels, mucous persons, who can
120/70; T –
membranes and soft communicate.
36.8oC
tissue. 3. Preventing the pain is
3. Foresee the need for pain one thing that a
OBJECTIVE: relief. patient experiencing it GOALS WERE MET
Reference:
 Facial can consider. Early
 grimace Johnson, Gross. intervention may
noted when 1998. Handbook of decrease the total
moving Oncology. p. 306-307. amount of analgesic
4. Acknowledge reports of required.
 Limited hip
pain immediately. 4. One’s perception of
and legs
range of time may become
motion distorted during
 Guarding painful experiences.
behavior Pain can be
noted aggravated with
 Swelling and anxiety and fear
redness especially when pain
noted in the is delayed. An
client’s left immediate response
thigh, knee, to reports of pain may
and calf decrease anxiety in
the patient.
5. Provide rest periods to
promote relief, sleep, and
relaxation. 5. One’s experiences of
pain may become
exaggerated as a
result of exhaustion.
Pain may result in
fatigue, which may
result in exaggerated
pain. A peaceful and
quiet environment
6. Encourage verbalization of may facilitate rest.
feelings about the pain.
6. Only the client can
judge the level and
distress of pain; pain
management should

7. Encourage and assist
client to do deep breathing
exercises.
Dependent:
1. Provide analgesics as
ordered, evaluate the
effectiveness and
inspect for any signs
and symptoms of
adverse effects.
be a team approach
that includes the
client. Very few
people lie about pain.
7. Deep breathing for
relaxation is easy to
learn and contributes
to pain relief and/or
reduction by reducing
muscle tension.
Dependent:
1. Effectiveness of pain
medications must be
evaluated individually
because it is absorbed
and metabolized
differently by patients.
Analgesics may cause
mild to severe side
effects.
Reference:
Nurseslabs, 2020