NAME: Maris, Diana Anne V.

DATE: 11/21,22,23/2022
CLINICAL INSTRUCTOR: Miriam G. Levidica SCORE:

ASSESSMENT DIAGNOSIS ANALYSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective:
“Ang sakit sakit niya lalo na
kapag gumagalaw ako at
tumatayo” stated by the
patient
Acute Pain related to Boils as Acute pain happens suddenly,
evidenced by discharge of pus starts out sharp or intense,
and blood and pain scale of 8 and serves as a warning sign
out of 10 of disease or threat to the
body. It is caused by injury,
surgery, illness, trauma, or
painful medical procedures
and generally lasts from a few
minutes to less than six
months. Acute pain usually
disappears whenever the
underlying cause is treated or
healed.
International Association for
the Study of Pain. (2022,
August 4). Acute Pain.
International Association for
the Study of Pain (IASP).
https://www.iasp-pain.org/res
ources/topics/acute-pain/
Short term:
Within 8 hours of
nursing intervention
● Patient will report
decrease level of pain
from 8/10 to 5/10.
Long term:
Within 7 days of nursing
intervention
● Patient uses
pharmacological and
non pharmacological
pain-relief strategies.
● Patient displays
improvement in
mood, coping.
● Patient will be free
from pain from 5/10
to 0/10
Perform a comprehensive
assessment of pain. Determine thethe most reliable source of
location, characteristics, onset, information about their pain.
duration, frequency,
quality, and severity of
pain via assessment.
(Independent)
The patient experiencing pain is
Thus, assessment of
pain by conducting an interview
helps the nurse in planning
optimal pain management
strategies.
Wayne, G. (March
19,2022). Acute pain Retrieved
from Acute Pain Nursing
Diagnosis & Care Plan -
Nurseslabs
After 7 days of nursing
intervention
Short term:
After 8 hours of nursing
intervention
● Patient was able to
experience lesser pain
and tolerable level as
manifested by: Pain
scale of 5/10, no facial
grimace noted, calm
and cooperative.
Long term:
● Relieving methods
and relaxation
techniques are
understood and
demonstrated.
● The patient report
relieved of pain with
a pain scale of 0 out
of 10

Pain scale: 8/10

Objective:
(+) guarding behavior
(+) facial grimace
(+) discharge of pus and
blood
(+) tenderness in left scrotal
area to perineal area
(+)increase urinary frequency
(+) scrotum increased in size
(+)Vital signs:
- BP: 130/90
- HR: 91 bpm
- RR: 18 bpm
Assess the client on the
factors that Alleviate pain
such as deep breathing
exercise
(Independent)
. ,
Assess the client's signs and
symptoms related to pain
(Independent)
Ask clients to describe
anything they have done to
alleviate the pain. These may
include, for example,
meditation, deep breathing
exercises, Information on
these alleviating activities
can be integrated into
planning for optimal pain
management.
Wayne, G. (March
19,2022). Acute pain
Retrieved from Acute
Pain Nursine Diagnosis &Care
Plan - Nurseslabs
Bringing attention to
associated signs and
symptoms may help
the nurse in evaluating the
pain, and it could also
assess if the patient has any
underlying conditions.
Wayne, G. (March
19,2022). Acute pain
Retrieved from Acute
Pain Nursing Diagnosis &
Care Plan - Nursestabs
Provide non pharmacologic Non-pharmacologic
pain management methods in pain management
(Independent) may include physical,
cognitive-behavioral
strategies, and lifestyle pain
management
Wayne, G. (March
19,2022). Acute pain
Retrieved from Acute Pain
Nursing Diagnosis & Care Plan
- Nurseslabs

Administered Diclofenac 2 Pain Medications could be

ampules in 500cc Plain administered if the client
Normal Saline at 20 micro cannot tolerate the pain
drops per minute, Wayne, G. (March
Parecoxib 40mg 19,2022). Acute pain
intravenously and tramadol Retrieved from Acute Pain
37.5mg + paracetamol Nursing Diagnosis & Care Plan
325mg once a day per - Nurseslabs
orem as per Doctors order.
(Dependent)
 abdominal and thoroughly
discomfort/pain. before swallowing.
(Nursestudy.net)

8. To determine if (GOAL MET)Patient

pharmacological and reported acceptable
non pharmacological comfort scale of 8/10
management is and normal vital sign:
effective - BP: 110/70
Wells N, Pasero C, McCaffery M. - HR: 89 bpm
(2008, Apr). Improving the Quality of - RR: 18 bpm
Care Through Pain Assessment and
Management. In: Hughes RG, editor.
Patient Safety and Quality: An
Evidence-Based Handbook for Nurses.
Rockville (MD): Agency for Healthcare
Research and Quality (US)
https://www.ncbi.nlm.nih.gov/books/
NBK2658/

9. Collaborate with a
dietician or physician 9. To provide a complex (GOAL MET) Referred
for nutritional support diet information. the patient to dietitian.
(Nursestudy.net)
(Collaborative)