Rhea Mae V.

Valles

BSN-III

Pt. L.L. 70y/o

Assessment Diagnosis Planning Intervention Evaluation

Subjective: Acute pain After 4 hours of Nsg. Action Rationale After 4 hours of
Medyo masakit related to nursing 1. Accept 1. Pain was a nursing
itong tahi ko as surgical incision intervention, the clients subjective intervention, the
verbalized by patient.
as evidenced by client has reported description of experience and clients pain
pain scale of 5, pain will subside. pain. cannot be felt was relieved.
Objectives: 10 as the highest Acknowledge by others.
c pain scale of and 0 as the the pain 2. Observations
5, 10 as the lowest, facial experience may be
highest and 0 grimace and and convey congruent with
as the lowest muscle acceptance of verbal reports.
c facial guarding. clients 3. To promote
response to non-
grimace
c muscle pain. pharmacologic
2. Observe pain
guarding
post surgical nonverbal management.
cues 4. To distract
incision
behaviors and attention.
V/S taken as
5. To reduce
follow: other
tension.
T:36.5 objectives
6. To reduce pain.
P: 96 defining 7. To be able to
R: 23 characteristic follow up the
BP: 120/70 s, as noted, situation of the
especially in patient.
 persons, who
cant
communicate
.
3. Provide
comfort
measures:
touch,
repositioning,
nurse
presence.
4. Encourage
diversional
activities like
socialization
of others.
5. Encourage
use of
relaxation
techniques:
focused
breathing,
imaging,
CD/tapes.
6. Instruct to
take dolax
100mg/5ml1t
sp BID for
pain, as
prescribe by
 the physician.
7. Cooperate
with the
family of the
client to
document the
health of the
patient.