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Acute Pain
ASSESSMEN NURSING SCIENTIFIC GOALS NURSING RATIONALE EVALUATIO
T DIAGNOSIS RATIONALE AND INTERVENTIONS N
OBJECTIV
ES
Subjective Unpleasant sensory Independent Goal met.
Acute pain related and emotional SHORT TERM: SHORT TERM:
to a break in the experience arising After 15-25 1. Anticipate need for 1. Early intervention After 15-25
continuity of from actual or minutes of pain relief. may decrease the total minutes of
“Masakit grabe femur secondary potential tissue nursing amount of analgesic nursing
noong nabali,” as to direct blow and damage or described intervention, required. intervention,
verbalized by the external trauma in terms of such pain may be 2. Respond pain was
client damage controlled as immediately to 2. Prompt responses controlled as
(International manifested complaint of pain. to complaints may manifested by:
Pain scale of 8/10 Association for the by: result in decreased
(using the Wong- Study of Pain); anxiety & pain *pain scale of
Baker FACES Pain sudden or slow onset *pain scale of perception in the 4/10 to 6/10
Rating Scale) of any intensity from 4/10 to 6/10 patient. * respiratory
Objective mild to severe with * respiratory 3. Eliminate rate of 28-35
an anticipated or rate of 28-35 additional stressors or 3. Patients may cpm
predictable end and a cpm sources of discomfort experience an
duration of less than whenever possible. exaggeration in pain if LONG-TERM:
V/S taken as
6 months. Fractures LONG-TERM: external factors are After 4 hours of
follows:
are cause by direct After 4 hours further stressing them. nursing
T: 36.8C
blows, crushing of nursing 4. Provide rest periods interventions,
P: 118 bpm
forces, sudden interventions, to client to facilitate 4. A quiet and relaxing client was able
R: 38 cpm
twisting motions, client will be comfort, sleep, and environment is toward to achieve
extreme muscle able to relaxation. facilitating rest and maximum pain
Presence of contractions. When achieve increasing pain relief as
Closed complete the bone is broken, maximum 5. Use non- tolerance. manifested by:
fracture in M3 of adjacent structures pain relief as pharmacological pain
left femur are also affected, manifested relief methods: 5. To decrease pain *pain scale of
resulting in soft by: without added side 0/10 – 2/10
Facial grimace tissue edema, effects of medications * pulse rate of
Moaning hemorrhage into *pain scale of a. Guided imagery 90-110 bpm
Crying muscles and joints, 0/10 – 2/10 a. The use of a mental * respiratory
Diaphoresis joint dislocations, * pulse rate picture or an imagined rate of 25-30
Guarding ruptured tendons, of 90-110 event involves use of cpm
behavior severed nerves, and bpm the five senses to * absence of
damaged blood * respiratory b. Distraction distract oneself from facial grimace
vessels. rate of 25-30 techniques (Breathing painful stimuli. * absence of
cpm modifications and moaning
* absence of nerve stimulation) b. Heighten one’s * absence of
facial grimace concentration upon crying
* absence of non-painful stimuli to * absence of
moaning decrease one’s diaphoresis
* absence of c. Relaxation awareness and * absence of
crying exercises (ROM on the experience of pain. guarding
* absence of unaffected side; static behavior
diaphoresis quadriceps exercise c. The goal of these
* absence of on the affected leg) techniques is to
guarding reduce tension,
behavior 6. Instruct patient to subsequently reducing
report pain. pain.

7. Acknowledge
existence of pain; 6. Relief measures
inform patient of may be instituted.