Activity:

Day 1 : FDAR/ NCP ( Pain)

Republic of The Philippines

Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City
Form No.:
NURSE’S NOTES Revision No.:
Effectivity Date:

Date
&Time
05/3/21 F: Acute pain related to inflammtaion and increase presure in the middle ear as evidenced by
reported pain scale of 8/10
7-3
D: Received lying on bed; “Masakit po yung tenga ko”; With reported pain scale of 8/10; With VS
as follows: T- 38.5 C, PR- 95 bpm,, BP-110/60 mmHg; With facial grimace and guarding reflex.
With feeling of discomfort and crying episodes.

A: Assessed pain characteristics according to pain scale for children to determine the level of pain
experienced; Assessed hearing ability frequently; Monitored and recorded vital sign; Observed for
nonverbal indications of pain, moaning, and guarding, crying and facial grimace; Provided rest
periods to promote relief, sleep and relaxation; Assisted to sit up, raise head on pillows or to lie on
unaffected ear; Applied heating pad or a warm water bottle; Administered prescribed medication
such as antibiotics; Encouraged to increase fluid intake to decrease susceptibility to infection;
Encouraged parents or significant others for support system; Instructed parents to give soft foods;
Instructed the family the use of a wam heating pad or an ice pack application

R: The patient was able to verbalize relief of pain from 7/10 to 3/10

NCP

Data Goals /Expected Action/ Nursing Rationale Response &

outcome Interventions Evaluation
STG: Within Dxt: After ___8____hr/s,
Subjective __8____hour/s of  Assess pain  To assess level NI the patient was able
Findings: NI the patient will characteristics of pain to verbalize relief of
-with reported be able to according to experience by pain
pain scxale of verbalize relief of pain scale for the patient as manifested/
8/10 pain children evidenced
-“Masakit po yung as manifested/  Assess hearing  To rule out by:
tenga ko”; evidenced ability worsening of pain scale from 8/10 to
by: frequently. underlying 3/10
pain scale from condition/devel
8/10 to 3/10 opment of
complications
and for further
Objective LTG: after _3__ planning of STG:
Findings: days of NI the effective fully/partially/un
- With VS as patient will be able treatment Met:
follows: T- 38.5 to display  Monitor and  A normal
C, PR- 95 bpm,, improved well recorded vital response to
BP-110/60 mmHg being and to be sign pain is an
-With facial free from any increase in After ___24___hr/s,
grimace and discomfort as respiratory rate, NI the patient was able
guarding reflex. manifested by heart rate, to display improved
-With feeling of normal vital signs and blood press well being and to be
discomfort and and improvement ure; fever may free from any
crying episodes. on his mood cause discomfort as
discomfort. manifested by normal
 Observe for  Pain is vital signs and
Focus/ Nursing nonverbal subjective improvement on his
Diagnosis: indications of experience and mood
Acute pain related pain, moaning, cannot be felt
to inflammtaion and guarding, by others LTG: fully
and increase crying and /partially/un
presure in the facial grimace Met
middle ear as Tct:
evidenced by  Provide rest  External
reported pain periods to stressors like
scale of 8/10 promote relief, noise tend to
sleep and exaggerate
relaxation physiological
pain
 Assist patient  Elevation
to sit up, raise promotes
head on pillows drainage and
or to lie on decreases
unaffected ear pressure from
fluid
 Apply heating  Heat increases
pad or a warm blood supply
water bottle and reduces
discomfort
 Administer  Analgesic such
prescribed as
medication acetaminophen
such as and ibuprofen
antibiotics alter response
to pain.
Edx:
 Encourage to  To decreases
increase fluid susceptibility to
intake to infection
decrease
susceptibility to
infection
 Encourage  Promotes
 parents or physical
significant comfort
others for and distraction
support system. for a child
experiencing
illness.
 Instruct parents  Movement of
to give soft the eustachian
foods tube, such as
with chewing,
may further
aggravate the
pain
 Instruct the  Heat promotes
family the use vasdialtion thus
of a wam reduces
heating pad or discomfort and
an ice pack cold compress
application decreases
edema and pain