NURSING

PROBLEM CUES DIAGNOSIS GOALS AND NURSING N.I. RATIONALE EVALUATION

AND OBJECTIVES INTERVENTIONS WITH
RATIONALE REFERNECES

#1 Subjective Nrsg Dx: After the shift, - Performed a - To determine After the shift,
Data: the patient will comprehensive possible the patient
Pain on the Acute pain r/t be able to report assessment of pain pathophysiological / verbalized:
upper -Pain scale of inflammatory pain is to include location, psychological “Mabuti-buti na
quadrants 8/10 process of the controlled as characteristics, causes of pain and ang pakiramdam
radiating to the blood vessels in manifested by onset, duration, how to treat it. ko.” With PS of
back -“Ang sakit ng the kidney. PS of 6-4/10 frequency, quality, 5/10.
tiyan ko. Ditto from 8/10, and and precipitating/
sa may Rationale: absence of aggravating factors.
bandang taas facial grimace
hanggang Acute and guarding - Provided comfort -To provide
likod.” As inflammati behavior. measures such as nonpharmacological
verbalized by backrubs and pain management.
on is
the patient change of position.
characteriz
Objective ed by five -(Dependent) - To
Data: cardinal Administered pain relieve/alleviate
signs: relievers pain.
- Changes in rubor (redness),
vital signs. calor (increased -Provided - To increase
heat), diversional patient’s pain
- Facial (swelling), activities such as threshold.
grimace dolor (pain), reading newspapers
and and listening to
- Guarding of functio laesa radio.
the upper (loss of
quadrants function).
- Sighing

- Self focusing