CUES NURSING DIAGNOSIS BACKGROUND GOAL & NURSING EVALUATION

  KNOWLEDGE OBJECTIVES INTERVENTIONS  

  WITH RATIONALE

Subjective Data: Acute pain related to NANDA-I Definition: Goal: The nurse:
progressive and Unpleasant sensory and
“8/10 kasi bumabalik consistent pain during emotional experience The client will be able Established a
yung sakit na episodes.. arising from actual or to be relieved from the therapeutic relationship
nararamdaman ko, potential tissue damage acute pain or based on trust and
nahihirapan talaga or described in terms of discomfort they have respect. (Establishing
akong such damage been experiencing and trust and unconditional
huminga at sumasakit (International will be able to regain acceptance are
ang dibdib ko pero sa Association for the comfortability and be necessary for a
ngayon medyo okay Study of Pain); sudden able to move freely. satisfactory therapeutic
naman na pero or slow onset of any relationship between
bumabalik intensity from mild to the nurse and patient)
pa rin talaga.” severe with anticipated  
or predictable end and a
”… Ang sabi pa niya duration of 6 months or Objectives:
hindi na niya talaga less. SHORT TERM
kaya kasi mas lalo
lang sumasakit.” NOC: Comfort NIC: Medication
level/Pain control Management
Pain lasts for about 5
minutes. After 2-3 hrs of nursing
interventions, the client
59 years old will be able to: 

Objective Data: 1. Increased 1.A Client’s 1. Client was able

participation in willingness to Increase
Admitted with a activities of (motivation) and ability participation in
diagnosis of CAP and recovery to participate activities of
Acute coronary 1.B Explain the recovery
syndrome. therapeutic uses of
menthol preparations,
Experiences chest pain massage, and vibration
with burning sensation on affected areas to
relieve some pain.

1.D Teach the client to

avoid negative thoughts
about ability to cope
with pain.

2.A Medicate for pain

2. Reduction in as needed. 2. Client was able
pain behaviors to reduce pain
behaviors and or
2.B Discuss with the sensations
client and family
noninvasive pain-relief
measures (e.g.,
relaxation, distraction,
massage).
2.C Explain the
expected course of the
pain (resolution).
2.D Provide the client
with written guidelines
for weaning from pain
medications when the
acute event is relieved.
 Long Term Long Term
1.A Assess the family’s
1. Educate family knowledge of pain and 1. The family and
and client on response to it. client was able
comfort to learn and
measures. 1.B Give accurate discuss comfort
information to correct measures that
misconceptions they feel is best
for the client.
1.C Provide each
family member with
opportunities to discuss
fears, anger, and
frustrations privately;
acknowledge the
difficulty of the
situation.

1.D Incorporate family

members in the pain-
relief modality, if
possible (e.g., stroking,
massage).

1.E Praise their

participation and
concern.