Cues Nursing Scientific Goal Nursing Action Rationale Evaluatio

Diagnosis Rationale Objective n

Subjective: .
The patient Acute Pain Pain is caused Short Term: 1. Monitor vital 1. Some analgesics Short term
verbalizes by soft tissue After a 1-3 signs decrease respiratory goal was
while Related hip damage and is days of effort and blood fully met.
sobbing fracture compounded by performing pressure. The patient
“Yung binti muscle spasms these performs
ko., masakit” As manifested by and swelling. nursing 2. Assess client’s 2. Assessment relaxation
the patient’s -Medical- actions the pain including provides clues to exercises
The client verbalization, Surgical patient will type, location, underlying cause of when in
rates the while sobbing Nursing 3rd ed. gain some and intensity. pain and provides pain. He
pain as 4-5 “yung binti by Lemone and ways of Use the 10-point baseline for also
on the pain ko., masakit” Burke coping with rating scale. developing showed
scale. and the client the pain appropriate pain signs of
rates the pain as thus making 3. Move the relief strategies. better pain
Objective: 4-5 on the pain it easier to client gently and toleration.
The patient scale and The cope with slowly 3. Gentle moving Goal fully
grimaces in patient the helps prevent the met.
pain even grimaces in discomfort development of
with the pain even 4. Encourage severe muscle pain
slight with the slight Long term: distraction or
movement movement of After a week, other non- 4. These help
of his left his left leg. the patient invasive methods decrease the focus on
leg. will be able as pain relief, the pain and may
to verbalize such as deep lessen the intensity of
that the pain breathing and pain.
is now other forms of
diminished relaxation.
and is much -Medical-Surgical
more Nursing 3rd ed. -Medical-Surgical
tolerable by Lemone and Nursing 3rd ed. by
than the Burke Lemone and Burke
previous
days.