PELAGIO, SHIENA MAE B.

BSN II-A

CASE: Cervical cancer

IMPLEMENTATION
Assessment Diagnosis Planning Evaluation
Nursing Intervention Rationale
Subjective: Acute pain After 3 hours of INDEPENDENT After 3 hours of
“I experience related to nursing  Perform a  Assessment is nursing
pelvic pain” as disease process intervention, the comprehensive intervention, the
the first step in
verbalized by as evidenced by patient will patient was able
assessment of managing pain. It
the patient verbal reports, report pain is to report pain is
facial mask of relieved/ pain to include helps ensure that relieved/
pain, distraction/ controlled location, the patient controlled
Objective: guarding characteristics, receives effective
 Guardin behaviors, onset/duration, pain relief.
g/ autonomic frequency,
responses, and
protecting quality, severity
restlessness
the affected of pain (0 to 10 or
site faces scale), and
 Facial aggravating
grimace factors
noted
 Diaphor  Assess and  Aside from as
etic noted monitor vital a baseline data,
 Restless signs early detection
ness noted from abnormalities
 V/S and early
taken as intervention could
follows: take place.
T: 36.5 OC  Provide
HR: 80 bpm comfort measures  To provide
RR: 25 bpm (e.g., back rub, nonpharmacologic
BP: 100/70 change of pain management.
mmHg position, use of
heat/cold) and
quite
environment

 Instruct in  To destruct
and encourage attention and
 use of relaxation reduce attention
exercises, such as
focused breathing

DEPENDENT:
 Pharmacologic
 Administer
al intervention to
pain medications
reduce pain
as ordered