Date Cues Need Nursing Patient Outcome Nursing Imple Evaluation

and Diagnosis Interventions menta

Time tion
F Subjective: C Acute Pain After 8-hours of  Obtain client’s February 2, 2022
E  “I am feeling O related to nursing perception of @ 3 PM
B tired and G distended intervention, the pain such as
R dizzy along N endocervix as client would be the location, 1 GOAL
U with an I evidenced by able to: characteristics COMPLETELY
A abdominal T facial mask of (stabbing, dull, MET
R pain in my I pain, guarding  Report pain at a sharp), onset,
Y lower left” V behavior and manageable duration, After 8-hours of

E verbalization level as frequency, nursing

2, Objective: / of abdominal evidenced by a quality, and intervention, the

 Restlessness P pain. pain scale of 3 intensity using client:

2  Discomfort E out of 10 or pain scale.
0 R Rationale: lesser, absence  Reported
 Grimace R:
2 C Ectopic of restlessness controlled
 Guarding To fully
2 E pregnancies in and facial mask pain as
behavior understand
P the later of pain. evidenced by
client’s pain
@ T stages causes a pain scale
symptoms.
7 U bleeding that  Verbalize of 3 out of 10,
A A leads to nonpharmacolo absence of
restlessness
M L phrenic nerve gical methods  Observe and facial
irritation that that provide nonverbal cues tension.
induces relief such as and pain 2

referred pain. deep breathing, behaviors such  Verbalized

(Levie, 2019) long as facial nonpharmacol
exhalations, expressions ogical
Domain 12 • and visualizing and body methods that
Class 1 • soothing language. provide relief
Diagnosis scenes. such as deep
Code 00132 R: breathing,
 Demonstrate Observations may long
the non- not be congruent exhalations,
pharmacologica with verbal reports and
l methods that or may be only visualizing
provide relief indicator present soothing
such as when client is scenes.
breathing and unable to
relaxation verbalize.  Demonstrated
techniques 3 breathing and
proficiently in  Assess skin relaxation
breathing, long color and vital techniques
exhalations and signs. proficiently
 visualizing R: such as long
soothing They are usually exhalations
scenes. altered in acute and
pain. Also, to visualizing
 Maintain normal acquire baseline soothing
vital signs, data. scenes.
especially blood 4
pressure and  Administer  Maintained
cardiac rate. prescribed normal vital
(110/70 – pain signs,
130/90 ; 60- medications especially
100) such as blood
analgesics. pressure and
R: cardiac rate.
To alleviate the (110/70 –
symptoms of 130/90 ; 60-
5
abdominal pain. 100)

 Place the
patient in
complete bed
rest
R: To provide
optimal comfort to
the client.

 Educate the 6

client in
regards to
performing
non-
pharmacologic
al pain relief
methods such
as deep
breathing, long
exhalations
and visualizing
soothing
scenes.
R: 7

To distract
attention and
reduce tension.
 Elevate the
head of the
bed and
position the
patient in a
semi-fowler’s.

R:
To increase 8
oxygen level by
allowing optimal
lung expansion

 Assess the
pain intensity
using a pain
scale of 10
being the
highest and 0
as the lowest.
R:
9
To determine
effectiveness of
the procedure.

 Encourage
verbalization of
feelings about
the pain such
as concern
about
tolerating pain,
anxiety,
pessimistic
thoughts.
R:
to evaluate coping
abilities and to
identify areas of
additional
concern.