ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective Acute Pain r/t After 8 hours of nursing Independent Goal met. Client reported that
surgical trauma as intervention, client will: Determine characteristics and location of Client may not verbally report pain and pain have been relieved and
“Agsakit sakit ti evidenced by: discomfort. discomfort directly. Comparing specific did not manifest further
sugat ko kasla lang Note verbal and nonverbal cues, such as characteristics of pain aids in differentiating evidence of pain. Followed
agpitikpitik,” as Reports of incisional Identify and use appropriate grimacing, rigidity, and guarding or postoperative pain from developing prescribed pharmacological
verbalized by the pain interventions to manage pain from developing complications complications (e.g., ileus, bladder retention regimen. Demonstrate use of
client Guarding behavior pain/discomfort. restricted movement. or infection, wound) relaxation skills and
Facial mask of pain. diversional activities, as
Objective 5 out of 10 pain Verbalize lessening of level of indicated, for individual
Observed evidence scale pain. Provide information and anticipatory Promotes problem solving, helps reduce situation.
of pain guidance regarding causes of discomfort pain associated with anxiety and fear of the
Appear relaxed, able to and appropriate interventions. unknown,
Facial mask; eyes sleep/rest appropriately. and provides sense of control.
lack luster, fixed
movement, grimace
Monitor skin color/temperature and vital In many clients vital signs are usually altered
Restless and sighing signs (e.g., heart rate, blood pressure, in acute pain.
respirations)
Pain scale: 5 out of
10
v/s: Reposition client, reduce noxious stimuli, Relaxes muscles, and redirects attention
T- 37.5 and Relaxes muscles, and redirects away from painful sensations. Promotes
PR- 60 beats/min attention away comfort, and reduces unpleasant
RR- 19 breaths/min offer comfort measures, e.g., back rubs. distractions, enhancing sense of well-being.
BP- 110/80mHg Encourage from painful sensations.
Promotes comfort, and
use of breathing and relaxation techniques
and reduces unpleasant distractions,
enhancing sense
distraction (stimulation of cutaneous
tissue). of well-being
Encourage presence and participation of
partner as appropriate.
Initiate deep-breathing exercises,
incentive spirometry, and coughing using
splinting procedures, as appropriate, 30
min after administration of analgesics.
Dependent
Administer analgesics, as indicated, to
maximum dosage, as needed.
Demonstrate/monitor use of self-
administration/patient-controlled
analgesia (PCA) for management of
severe, persistent pain.
Evaluate/document client’s response to
analgesia, and assist in
transitioning/altering drug regimen, based
on individual needs.
Deep breathing enhances respiratory effort.
Splinting reduces strain and stretching of
incisional area and lessens pain and
discomfort associated with movement of
abdominal muscles. Coughing is indicated
when secretions or rhonchi are auscultated.
To maintain “acceptable” level of pain.
Notify physician if regimen is inadequate to
meet pain control goal.
PCA using meperidine or morphine may be
used to provide rapid pain relief without
excessive side effects/oversedation.
Enhances sense of control, general well-
being, and independence.
Increasing/decreasing dosage, stepped
program (switching from injection to oral
route, increased time span as pain lessens)
helps in self-management of pain.