Cues/Needs Nursing Diagnosis Rationale Goals and Objectives Interventions Rationale Evaluation

Subjective Data: Acute pain related to Pain is an unpleasant  After 6 hours of Independent: After 6 hour of nursing
inflammation. sensory an emotional nursing intervention the patient was
“Masaki ang lalamunan ko experience arising intervention the  Work with the patient to  Involving the patient in pain – able to rate the pain in a
pagkumakain ako.” As As evidenced by: patient will rate the identify the most effective control strategies promotes a
verbalized by the patient. from actual or scale of 4.
pain in a scale of 4. ways to control the pain. sense of mastery that reduces
potential tissue
 Discomfort of (0-10, 10 is the fears and helplessness or loss After 8 hours of nursing
Objective Data: damage. highest) of control.
the patient, intervention, the patient
restlessness,  Analyze and document pain  Careful analysis of pain
 Discomfort of the was able to report that pain
and irritability characteristics systematically. characteristics aids in the
patient, was controlled and relieve.
of the patient.  After 8 hours of For the precipitators, quality, differential diagnosis of pain.
restlessness, and
 Facial nursing region and radiation, severity, Systematic analysis prevents
irritability of the
grimacing intervention the and tine or frequency and hasty a possibly inaccurate
patient.
patient will report duration. conclusions about the quality
 Facial grimacing that pain controlled or probable cause of pain.
 The patient rate the and relieved.  Monitor continually for  As a result, verbal reports
pain in a scale of 8. possible indications of pain, alone may not adequately
(10 is the highest including verbalization, indicate the presence and
and 0 is the griming, diaphoresis, tense degree of pain. However
lowest.) posture, splinting, changes in vital signs toward
restlessness, irritability, normal even in the presence
emotional withdrawal, and of continued pain. Astute
changes in vital signs. observation may provide
ongoing protection against
unreported or underreported
pain.
 Reduce factors that may  Listening to the patient
increase pain, such as anxiety respectfully and implying an
that reports of pain won’t be alliance against pain help
believed, a sense of isolation, reduce anxiety.
and fatigue.  Abdominal pain is usually
 Provide bed rest and quiet reduced by rest and quiet
environment and minimizing environment.
visitors.