PAIN

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

SUBJECTIVE Acute pain Within 30-1 -Perform pain -To determine and After 5 days of 3
DATA: related to hours assessment to rule out hours
headache of nursing evaluate the worsening of an of nursing
evidence by intervention, characteristics underlying condition intervention, goals
stress, the of pain. or are
“dumalas ang
pulsating The client will Note and development of fully met. The client
pagsakit ng
sensation be able investigate complications was able to report
ulo ko parang
and to report changes decreased sensation
may tumitibok
pain scale of decrease from previous and
sa Sa right
6/10 of pain. reports non-recurrence of
side ng mukha
-Monitor vital pain as evidenced by:
ko, tuwing hapon
signs > Pain scale of 0 out
at gabi”
Within 1-2 of 10
- Promote > Verbalized
As verbalized days
wellness adequate
by the patient. of nursing
(Teaching - To prevent fatigue rest period and
intervention,
Considerations): that can lead to provide
-Stress the
-Encourage headache calm environment.
- Poor lifestyle The client will
adequate rest > Absence of facial
Activity be able
periods. Follow grimace
to verbalize
a regular
OBJECTIVE relieve of
sleep schedule
DATA: pain. Goal met
-Provide calm
and quite
-Vital signs Environment

BP: 110/80 -Include physical

mmHg activity in
RR: 22 daily routine.
PR: 103 Try a daily
walk or other
-Pain scale of moderate
6/10 aerobic
-Facial grimace exercise.
 FEVER
ASSESSMENT NURSING PLANNING INTERVENTIO RATIONALE EVALUATION
DIAGNOSIS N

SUBJECTIVE DATA: Hyperthermia After 4hrs of Monitor heart Dysrhythmias After 4hrs. Of
related to nursing rate and and ECG nursing
“I feel like my body dehydration interventions, rhythm. changes are interventions,
is burning and I feel the patient will common due the patient was
hot” maintain core to electrolyte able to maintain
temperature imbalance and core
As verbalized within normal dehydration temperature
by the patient. range. and the direct within normal
effect of range.
OBJECTIVE DATA: hyperthermia
on blood and
Flush skin, warm to cardiac tissues.
touch.

Restlessness
To minimize
Vital Signs Taken as shivering.
follow:

T:38.1 Wrap
P:70 extremities To offset
R:19 with cotton increased
BP:110/90 blankets oxygen
demands and
consumption
Provide
supplemental
oxygen.