Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Cues: Short Term: Independent: Short Term:

Kumikirot po hita ko, Acute pain related Within 30 min to 1 Investigated reports of Helpful in assessing After 1 hour of nursing
masakit po kahit hindi bone marrow filled hour of nursing pain using Universal need for intervention; it intervention, based on
hawakan at mas masakit po with leukemic cells intervention, the Pain Assessment tool. may helpful in assessing Universal Pain
kapag nagagalaw or as evidenced by patient’s feeling of further complication. Assessment Tool,
ginagamit ko pang lakad as reports of pain by the pain will be relieved patient reported the pain
verbalized by the patient. patient. and will be able to Monitored Vital signs Useful for evaluating the scale at 3/10, as the
appear relaxed and and noted nonverbal effectiveness of the patient looked relaxed
Objective Cues: able to rest cues, for example, intervention. and fully rested.
appropriately. Pain muscle tension and
 Temp: 39°C scale of 7 will be restlessness. Long Term:
 BP: 130/90 lowered to 3.
 PR: 120 Provided soothing Promote rest and After a week of nursing
 RR: 25 Long Term: environment to reduce enhances coping intervention, patient was
 Pain scale of 7/10 stress stimuli. Limited abilities. able to demonstrate
 Anemia After 1 week of the noise, lighting, and behaviors to manage the
nursing intervention, constant interruption of pain as he followed the
 Bruising
patient is going to be rest. comfort measures I
able to demonstrate taught.
behaviors on how to Placed in position of Improve tissue
manage pain comfort to support the circulation and joint
joints, placed pillows or motility.
padding in extremities.

Encouraged the use of Facilitates relaxation,

stress management augments
techniques, taught pharmacological
relaxation and deep- therapy, and enhances
breathing exercises, coping abilities.
guided imagery, and
visualization.

Dependent:

Administered analgesics
such as Tylenol as the Given for mild pain not
physician ordered relieved by comfort
measures
Administered Opioids
such as morphine Used when the pain is
severe, use of patient-
controlled analgesia is
beneficial in preventing
peaks and valleys
associated with
intermittent drug
administration and
increases patient’s sense
of control.
Administered
antianxiety agents such May be given to
as diazepam enhance the action of
analgesics or opioids.