ACTUAL NCP-1

ASSESSMENT EXPLANATION OBJECTIVE NURSING RATIONALE EVALUATION

OF THE INTERVETION
PROBLEM
Subjective: The unpleasant feeling After the 15 min of Assess the location,  helps planning optimal pain After the 15 min of
of pain is highly nursing intervention the characteristics, onset, management strategies, and nursing intervention the
“She complains of pain subjective in nature patient will be able to : duration, frequency, quality, to evaluate client’s cognitive patient was
behind and in front of that may be and severity of pain. status in relation to the
her left ear. She is experienced by the  . Recognize pain client’s present condition able to:
exhibiting unilateral patient. pain is “an onset and causal
facial paralysis.” factors  Recognize pain
unpleasant sensory and onset and
emotional experience  Acknowledge
Objective: the non-  To determine changes in describe causal
associated with actual these vital signs often factors
 left eye is or potential tissue -pharmacologica
l method to Assess and monitor vital indicate acute pain and associated with
drooping damage, or described discomfort her pain
 inability to reduce the pain signs, noting tachycardia,
in terms of such  Verbalize the
raise her eye hypertension, and increased
damage non-
 puff out her respiration
 To enhance awareness of -pharmacologic
cheeks al method to
the client
BP: 148/60 After the 1 hour of regarding her reduce the pain
Assist the client and provide
nursing intervention the information present condition After the 1 hour of
T: 36. patient will be able to: regarding present new nursing intervention the
PR: 83  interventions, condition and risk that patient was able to:
the client will accompany it  This clams & soothes the
RR: 26 patient  Demonstrate
report pain Provide comfort measures less feeling of
NURSING relieved or such as deep breathing pain
DIAGNOSIS controlled exercises  Verbalize
 Verbalize feeling of less
Acute pain R/T facial
feeling of less pain and
muscle weakness or  To promote pain relive
pain and discomfort
paralysis Administer pain reliever
discomfort
medication as prescribed

Provide eye care & Apply  To protecting the eye from

eye ointment to keep eyelids dryness and promote
ACTUAL NCP-1

closed, an comfortable

 to stretch and mobilize

Educate pt. how to perform
facial massage gently
facial muscles until the
nerve has repaired itself. It
is important to promote
circulation which will
encourage nerve repair

 help in reducing symptoms

Instruct patient to chew on

the unaffected side of his
mouth and diet rich in
vitamins and minerals,
Eliminate hot fluids and
foods.