St.

Paul College of Ilocos Sur

(Member, St. Paul University System)
St. Paul Avenue 2727, Bantay, Ilocos Sur

DEPARTMENT OF NURSING
BACHELOR OF SCIENCE MAJOR IN NURSING

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: Acute pain Short Term (Independent) After the nursing

“ Sumasakit ang kaliwang - Within 15-30 mins of - Perform assessment to - To identify and rule out intervention, goals are fully
tenga ko.” as verbalized nursing intervention evaluate characteristic worsening of met. The client was able to
by the patient. the patient will be able of pain. underlying condition or report decrease sensation and
to report decreased of development of non-recurrence of pain as
pain. complications evidenced by the patient.
Objective Data: Long Term - Monitor vital signs - To monitor patient’s
- Irritable - Within 2-3 days of health status
- Pain rated as 8 out of nursing intervention - Position the patient in - To promote non-
10 the client will be able a relaxed position. pharmacological pain
- Vital Sign to verbalize relieve of - Advice breathing management and
pain. technique, massage, reduce tension
 Temp: 37.2 imagery.
 PR: 120
 RR: 20 - Apply cold compress - it has an numbing
on head and neck effect that may dull the
- Encourage adequate sensation of pain.
rest periods. Follow - To prevent fatigue that
regular sleep scheduler can lead to headache
and encourage to

RAMOSKRISTINEANGIE@GMAIL.COM 1
 avoid exposure to
radiation

- Increase fluid intake

- Being hydrated can
prevent migraine
attack

RAMOSKRISTINEANGIE@GMAIL.COM 2