ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Acute Pain related to Patient demonstrates • Obtain client’s/SO’s Report pain is relieved
psychological stressors the use of appropriate assessment of pain to or controlled.
as verbalize by the client diversional activities and include location,
relaxation skills. characteristics, onset, Verbalize non-
duration, frequency, pharmacological
Patient describes quality, intensity. methods that provide
satisfactory pain control Identify precipitating or relief.
at a level less than 3 to aggravating and
4 on a rating scale of 0 relieving factors in Response to
to 10. order to fully understand interventions, teaching,
client’s pain symptoms. and actions performed.

• Assist in thorough
evaluation, including
neurological and
psychological factors
(pain inventory,
psychological interview),
as appropriate, when
pain persists.

• Provide comfort
measures (e.g., touch,
repositioning, use of
heat or cold packs,
nurse’s presence), quiet
environment, and

calm activities to
promote non-
pharmacological pain
management.

• Encourage diversional
activities (e.g., TV/radio,
 socialization
with others).

• Discuss impact of pain

on
lifestyle/independence
and ways to
maximize level of
functioning.

Risk for Allergic Be free of signs of •Question client Client’s response to

Response related to hypersensitive response regarding known interventions, teaching,
almond consumption as allergies upon and actions per-
verbalize by the patient Verbalize understanding admission to formed.
of individual risks and healthcare facility.
responsibilities in Response to
avoiding exposure •Obtain a written list of medications
drug allergies upon first administered.
contact with
client. Response to
medications
•Discuss client’s current administered.
symptoms, noting
reports of rash, hives,
itching; teary eyes;
localized swelling or
diarrhea; nausea; a
feeling of faintness.
Ascertain if client/care
provider associates
these symptoms with
certain food,
substances, or
environmental factors.

OBJECTIVES CONTENT METHODS OF TIME ALLOTED RESOURCES METHODS OF

 OUTLINE TEACHING EVALUATION
Demonstrate use of •Develop good 1:1 instruction or 30 minutes Sleep cycle charts, Response to
relaxation skills and sleep habits teaching Medicine tray, interventions,
diversional inspirational videos teaching, and
activities, •Take medicine as actions performed.
as indicated, for prescribed
individual situation. Attainment or
•Reduce stress in progress toward
client’s life desired outcome(s).

Verbalize •Identify 1:1 instruction or 30 minutes Images and videos Response to

understanding of signs/symptoms teaching related to her health interventions,
individual risks and requiring prompt concern teaching, and
responsibilities in response actions performed.
avoiding exposure
•Verbalize Attainment or
Be free of signs of understanding of progress toward
hypersensitive individual risks and outcomes.
response responsibilities in
avoiding exposure
Client’s Personal Data:
Name: Chavez, Mary Grace
Age: 19 years’ old
Height: 152 cm
Weight: 68 kg