BUGO, JANNA MARIE J.

BSN 3-YA-1

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Acute pain Short term: Independent: Independent Short Term:

SUBJECTIVE related to stab After 2 hours of After 2 hour of nursing
wound on the nursing 1. Assess for potential types of 1. To aid in understanding intervention, patient will:
“Masakit po sa left chest in the intervention, the pain that may be affecting reason for severity of pain
bandang kaliwang midaxillary line patient will: client. associated with client’s Verbalized reduced pain
dibdib ko at as evidenced by condition, and point from pain scale of 10/10 to
nahihirapan ako agony, SOB, and Report relief or 2. Note client’s age and toward needed 8/10.
huminga.” subscapular controlled pain. developmental level and interventions for pain
pain. current condition. management. Report relieved and
OBJECTIVE Rate the pain controlled pain.
scale lower than 3. Encouraged used of stress 2. It affects the ability to
P: 91 bpm the initial rate at a management techniques report pain parameters or Utilized relaxation skills
BP: 129/71 mmHg level that is such as deep breathing response to pain and pain and diversional activities,
SpO2: 97 acceptable to exercises. management as indicated, for individual
RR: 26 them or 0/10. interventions. situation.
T: 37.2 C 4. Perform assessment each time
Demonstrate use pain occurs. Document and 3. Refocuses attention, Long Term:
-irritation of relaxation skills investigate changes from promotes relaxation, may After 6 hours of nursing
and diversional previous reports and evaluate enhance coping abilities. intervention, patient was
-distress due to pain activities, as results of pain interventions to able to breath with normal
indicated, for demonstrate improvement in 4. To identify worsening of pattern, (-) facial grimace,
- Pain Scale: 10/10 individual status. underlying rated pain as 3/10 and was
situation. condition/developing able to sleep and rest. Vital
- facial grimace 5. Provided calm and restful complications. signs were also normal
Long term: environment. with BP: 125/81; RR:
- Sob After 6 hours of 5. Reduce patients' anxiety 20cpm; HR: 87 bpm and T:
nursing Dependent: and stress, accelerate 36.7°C
-heavy breathing intervention, the recovery, shorten
patient will: 1. Administer analgesics, as hospitalizations, reduce
indicated, to maximum medication use, lessen
Manifest vital dosage, as needed. pain, and promote a sense
signs within of well-being.
BUGO, JANNA MARIE J.
BSN 3-YA-1

normal limits. 2. Assess the appropriateness of

a patient-controlled analgesia
(PCA) pump.
Dependent:
1. To maintain “acceptable”
level of pain. Notify
physician if regimen is
inadequate to meet pain
control goal. Combinations
of medications may be
used on prescribed
intervals.

2. Assess if the patient is a

PCA candidate. PCA is the
IV infusion of opioids
through a pump controlled
by the patient. If the
patient meets the criteria,
this can be a more effective
method of pain
management. PCA enables
patients to self-administer
analgesia and gives the
patient some degree of
control over the dosage
they receive. It is important
to assess if the patient is
both physically able and
willing to hit the PCA
button but also mentally
competent to understand
that doing so will relieve
their discomfort.