Date/ Cues Need Nursing Patient Outcome Planning of Implementation Evaluation

Time Diagnosis Intervention

M Subjective: C Acute pain After 30 minutes of  Position the 2 March 6. 2021
A - “Sakit jud O related to bone nursing intervention, client in a @ 8 AM
R kaayo G swelling (femur) the patient will be able comfortable
C akong N as evidenced by to manifest absence of position GOAL MET
H bukog sa I crying, grimaced pain as evidence by: R: To promote
pa-a” as T face, irritability, a. Verbal comfort and After the 30
6, verbalized I and guarding confirmation of relaxation minutes of
by the V behavior absence of pain  Promote the nursing care the
2020 patient E b. Pain scales of use of diversion 5 patient’s pain
@ - Rationale: 2/5 activities like was relieved as
7:30 Objective: P Osteomyelitis is c. Absence of reading books, evidenced by:
AM - Pain scale E an infection in the crying watching TV,
of 4/5 R bone. Infections d. Absence of etc. a. “Wala na
- Crying C can reach a bone grimaced face R: To draw the kaayo
- Grimaced E by travelling e. Absence of attention of the nagsakit”
face P through the irritability patient away as
- Irritability T bloodstream or f. Absence of from pain verbalize
- Guarding U spreading from guarding  Instruct family to d by the
behavior A nearby tissue. behavior eliminate 7 patient
- (+) Swelling, l Signs and environmental b. Pain
warmth and symptoms of stressors scale of
redness at P osteomyelitis R: To avoid 2/5
right thigh A includes bone additional stress c. (-) crying
- RR: 28 T inflammation, to the patient d. (-)
- PR: 110 T swelling, warmth and promote grimaced
- HR: 108 E and redness over comfort face
- (+) Bone R the area of  Administer pain 1 e. (-)
abscess as N infection and reliver irritability
seen on pain. f. (-)
 MRI medication as guarding
- (+) Reference: prescribed behavior
Staphylococ Mayo Clinic R: To relieve
cus Aureus (2020). pain and
bacterial Osteomyelitis. discomfort 3
culture from Retrieved March  Perform cold
bone biopsy 6, 2021 from application
https://www.mayo R: To reduce
clinic.org/disease pain,
s- inflammation
conditions/osteo and muscle
myelitis/symptom spasticity by
s-causes/syc- decreasing the
20375913 release of pain-
inducing
chemicals and
slowing the
conduction of
pain impulses
 Promote bed 4
rest and
immobility
R: To lessen
accidental
contact to the
site and
promote comfort
 Guided imagery 6
R: To divert the
attention of the
patient away
from pain
References:

Wayne, G. BSN, RN (2020). Acute Pain Nursing Care Plan. Retrieved March 6, 2021 from
https://nurseslabs.com/acute-pain/