Institute of Nursing

Gabriel Tolentino
BSN135-group 139A
5/07/2010
Nursing Diagnosis Objectives and goals
Acute pain related Goal: After 3 hours of
to acute nursing intervention the
appendicitis client will be able to report
of reduced pain.
Objectives:
Subjective:
After nursing intervention
>Reports of pain.
the client will be able to
referred pain.
Objective:
After nursing intervention
>Facial Grimace
the client will be able to
>Muscle guarding rate pain.
After nursing intervention
the client will be able to
verbalize pain.
After nursing intervention
the client will be provided
by comfort measures.
After nursing intervention
the client will be able to do
diversional activities.
After nursing intervention
the client will be able to
demonstrate use of
relaxation skills and
diversional activities.
Interventions
Together with the client locate
the location of pain and assess
for referred pain, as appropriate. dysfunction requiring treatment.
Assess the level of pain using
the pain rating scale.
Encourage verbalization of
feelings about pain.
Provide comfort measures,
quiet environment, and calm
activities.
Encourage diversional activities
(e.g., TV/radio, socialization
with others)
Encourage relaxation
techniques, such as focused
breathing, imaging CD/tapes.
Work client to prevent pain.
Use flow sheet to document
Rationale evaluation
After 3 hours of
nursing intervention
the client report
reduced pain.
Relaxation and
diversional activities
done.
To help determine possibility of
underlying condition or organ
To rule out worsening of
underlying condition or
development of complications.
Verbalizing of pain help reduce
level of pain.
To promote nanpharmacological
pain management.
Refocuses attention, promotes
relaxation, and may enhance
coping abilities.
To distract attention and reduce
tension.
Being informed about progress of