ASSESSMENT NURSING RATIONALE PLANNING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Acute Pain r/t Acute pain GOAL:
Subjective: on often results After 5 hours of
accumulation from tissue nursing
“Masakit ang tiyan ko. of fluid in the damage, such interventions,
Parang ang bigat bigat abdomen as a skin burn the client will be
ng tiyan ko” evidenced by or broken able to control
verbal reports bone. Acute her pain.
Objective: of pain in the pain can also
abdomen be associated OBJECTIVES:
• Restlessness with
• Irritability headaches or 1. After 5 1. Nurse will provide The client needs to 1. Was the client
• Facial grimace muscle minutes of health teaching on understand the able to
cramps. This nursing the importance of importance of pain understand the
Vital signs: type of pain intervention, the pain relief. relief to get his need to relieve
B.P. – 110/70 usually goes client will be able cooperation. the pain?
P.R. – 103 away as the to understand
R.R. – 19 injury heals or the need to ___Yes
TEMP. – 36.9 the cause of relieve the pain. ___ No, Why?
the pain
(stimulus) is
removed. 2. After 15
minutes of 2. Perform an
intervention, the assessment of pain Assessing the 2. The client was
client will be able including the characteristics of pain able to verbalize
to verbalize the location, will help in planning the location,
location, characteristics, what type of characteristics,
characteristics, onset/duration, intervention will be onset-duration,
onset-duration, quality, and severity done to reduce the quality and
quality and (0-10 on pain scale) client’s pain. severity of pain.
severity of pain. Note any presence
of deviations. ___Yes
3. After 3 hours ___ No, Why?
of nursing
intervention, the 3. Assist client to
client will be able explore methods for 3. The client was
to manage the alleviation/control of This will guide/help able to
pain. pain. the client in alleviate/control
alleviating/controlling pain.
Encourage his/her pain.
verbalization of ___Yes
feelings about the ___ No, Why?
pain. This is to help the
client voice out his/her
feelings regarding
his/her condition for
the healthcare provider
to know the current
Administer situation of the client.
medications as
ordered. Administering
medications such as
analgesics will help in
4. The client will pain relief.
be able to
practice self- 4. Encourage
care. adequate rest
periods. This is to prevent 4. The client was
fatigue. able to practice
Review ways to self-care.
lessen pain,
including This is for the client to ___Yes
techniques. gain knowledge on ___ No, Why?
how to manage pain
when possible
reoccurrence of
condition occurs.