Patient Name: Dizon, Carmelita Age: 87-year-old

Chief Complaint: Complains of pain at 6/10 for a “sore right shoulder”

Diagnosis: Date Identified: December 14, 2020

Problem: Pain at 6/10 for a “sore right shoulder” Date Evaluated: December 14, 2020
ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION
INFERENCE
Subjective data: Acute pain Acute pain is After 8 hours of Independent: Short term goals:
“Sakit akoang tuo nga related to sore an experience nursing
abaga loy.” as verbalized as evidenced that is known interventions the Short term interventions: - Goal met.
by the patient large amount of to virtually all patient will be able
bruising at the human beings. to: 1. Obtain full description of - Pain is a - After 8 hours of
right shoulder It is an pain from patient subjective nursing
with pain scale unpleasant Short term goals: including location, experience and interventions the
of 6 out 10. feeling that can - Verbalize intensity (using scale of must be described patient was able to:
be described relief/control 0–10), duration, by patient. Provides
as highly of shoulder characteristics and baseline for - Verbalize
subjective as a pain within radiation. Assist patient comparison to aid in relief/control of
person appropriate to quantify pain by determining chest pain within
experiences it. time frame comparing it to other effectiveness of appropriate time
Acute pain can for experiences. therapy, resolution frame for
have a sudden administered and progression of administered
Objective data: or slow onset medications. problem. medications. From
with an (By asking) pain scale of 6 to 3.
intensity From pain
- Complains of pain ranging from scale of 6 to 2. Monitor and document -Variation of - Display
for a sore right mild to severe. 3. characteristic of pain, appearance and reduced tension,
shoulder (Psychol, - Display noting verbal reports, behavior of patients relaxed manner,
2011) reduced nonverbal cues in pain may present ease of movement.
- Pain scale of 6 out tension, (moaning, crying, a challenge in
10 relaxed grimacing, restlessness, assessment. Most
manner, diaphoresis, clutching of patients with an
- Large amount of ease of chest) and BP or heart acute MI appear ill, Long term goal:
bruising noted to the movement. rate changes. distracted, and - Goal partially
right shoulder. focused on pain. met
Long term goal: Verbal history and
deeper investigation
- Vital signs as follows;
- Demonstrate of precipitating
use of factors should be
 BP-130/86, T postponed until pain
relaxation
-37.1 C is relieved.
techniques.
 P-94, Respirations may
 R- 22 be increased as a
 O2 sat- 95% result of pain and
associated anxiety;
release of stress-
induced
catecholamine
increases heart rate
and BP.

3. Review history of the -Decreases external

pain stimuli, which may
aggravate anxiety
and cardiac strain,
limit coping abilities
and adjustment to
current situation.
 -Delay in reporting
4. Instruct patient to report pain hinders pain
pain immediately. relief and may
Provide quiet require increased
environment, calm dosage of
activities, and comfort medication to
measures. Approach achieve relief. In
patient calmly and addition, severe
confidently. pain may induce
shock by stimulating
the sympathetic
nervous system,
thereby creating
further damage and
interfering with
diagnostics and
relief of pain.

5. Encouraged patient to
have enough rest and -To avoid
sleep. complications

- To promote
6. Support patient optimal patient
emotionally and mentally. comfort.

Long term intervention:

7. Instruct patient to do -Helpful in

relaxation techniques: decreasing
deep and slow breathing. perception and
Assist as needed. response to pain.
Provides a sense of
having some control
over the situation,
increase in positive
Dependent attitude.

1. Provide medications - To promote pain

per physicians’ order. relief and patient
comfort.