ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

Subjective Data Acute pain related After 8 hours of 1. Assess client’s 1. Pain scale After 8 hours of
to otitis media as nursing description and measures the nursing
“There are manifested by ear intervention, the frequency of pain; changes in the intervention:
episodes of ear discharges, patient will Use a pain rating level of pain by
ache followed by alterations in sleep experience relief scale. Observe if different providers. The patient
some discharges pattern and a pain from pain as the infant is Preverbal infants verbalizes relief
on his ear for 2 scale of 10. evidenced by: tugging or rubbing vigorously pull or from pain
weeks. The pain an ear. rub the affected
was severe at the Decrease ear ear, roll the head The patient’s
middle of the night discharges 2. Administer pain and appear sleeping pattern
which makes him medication such as irritable. has returned to its
hard to fall asleep,” Normal sleeping acetaminophen or 2. Analgesic such normal state
as verbalized by pattern ibuprofen as as acetaminophen
the patient’s prescribed and ibuprofen alter Discharges from
mother. response to pain. the patient’s ear
3. Have the child have decreased
Objective Data sit up, put pillows 3. Elevation
behind the head, or promotes drainage Goal was met
Ear discharges lie on the and reduces
Overall tired look unaffected ear. pressure from fluid.
Facial Grimace
Wong Bakers Face 4. Encourage and
Pain Scale of 10 assist the parent to 4. Promotes
hold and comfort physical comfort
the client. and distraction for
a child
5. Instruct the use experiencing
of a warm heating illness.
pad or an ice pack 5. Heat promotes
application. Advise vasodilation thus
parents to turn the reduces
heating pad on low discomfort; Cold
and cover it with a compress may
towel to ensure decrease edema
safety and pain.
6. Promote patient
bed on rest. 6. Promoting bed
rest ensures the
patient’s recovery
and can improve
sleeping pattern