Patient:

Dx:
Procedure done:

Assessment Nursing Scientific Analysis Goals/Objectives Interventions Rationale Evaluation

Diagnosis
Subjective: Acute pain The client is Short term: 1.) Perform a comprehensive 1.) Pain is a subjective Short term:
related to experiencing pain due assessment of pain including experience and must be
- Masakit yung tahi ko post- to the incision done to After 2 hours of nursing its location, characteristics, described by the client After 2 hours of
at hirap akong operative him during his intervention/s, the patient onset, duration, quality, in order to plan an nursing intervention/s,
gumalaw; Hindi ako surgical nephrectomy. Pain is a will report pain to a intensity. effective treatment. the patient reported
makatulog ng incision typical sensory manageable level. The 2.) Encourage relaxation 2.) Breathing deeply reduced pain and a pain
mahimbing dahil experience that may be initial pain score of 7/10 techniques & deep breathing oxygenates the blood, score of 4/10.
kumikirot as described as the will be reduced to at least exercises which causes our brain
verbalized by the client unpleasant awareness 4/10. 3.) Encourage diversional to release endorphins Long term:
- Pain score of 7/10 of a stimulus or bodily activities like watching that help reduce stress
harm. Individuals Long term: television, etc. to lessen pain. in the body and After 8 hours of
Objective: experience pain by 4.) Provide analgesics as decrease levels of pain. nursing intervention/s,
various daily hurts and After 8 hours of nursing prescribed by the attending 3.) To divert attention the patient reported
- facial grimace present aches, and occasionally intervention/s, the patient physician that somehow pain into a manageable
- guarding of the through more serious will report a pain score of decreases pain and level compared to the
affected area injuries or illnesses. 2/10. discomfort felt by the initial assessment. Pain
- Vital Signs as patient. score of 2/10.
follows: 4.) Analgesics or
BP: 140/100 painkillers is member
RR: 26 of the group of drugs
HR: 112 used to achieve
analgesia, which means
relief from pain.