ASSESSMENT DIAGNOSIS PLANNING INTERVENTI RATIONALE EVALUATION

ON

Subjective: Acute Pain STG: INDEPENDE STG:

“Masakit akon related to After 30-45 NT: After 30-45
tiyan”, as disease mins of - Establ - To mins of nursing
verbalized by process as nursing ished gain interventions
the patient. intervention rappor patien the patient will
evidenced
s the t t trust be able to
by patient able - Asses - Knowi demonstrate
Non verbal to s the ng the relaxation
Objective: cues demonstrat level level techniques to
- Guardin such as e relaxation of of mitigate pain
g guarding techniques pain, pain and reports a
behavior behavior to mitigate locatio that is minimized
- (+) facial and (+)facial pain and n, and felt so discomfort by a
grimace grimace and reports a scale it can pain scale of
- (+) (+) irritability minimized of help 3/10 and goal
irritabilit discomfort pain deter was partially
y by a pain mine met.
- Pain scale of appro
scale 3/10 priate
8/10 interv
ention
- Obser s
vation - Chan LTG:
of vital ges in After 7-8 hrs or
LTG: signs vital nursing
After 7-8 every signs, interventions
hrs or 4 hrs. especi the patient will
nursing ally be able to:
intervention tempe
s the rature - Reports
patient able and relief of
to: pulse pain
rate is with a
- Rep one pain
orts indicat scale of
relie ion of 1/10
f of increa - Patient
pain sed report a
with pain restored
a experi health
pain enced status
scal - Instru by the and
e of ct client ability to
1/10 client - Relax perform
- Pati to ation activities
ent perfor techni - The
 repo m ques patient
rt a relaxa can report
rest tion make that pain
ored techni the is
heal ques client relieved
th feel and
stat comfo controlle
us rtable d and
and and a the goal
abili little was met
ty to distra
perf ction
orm to
acti divert
vitie the
s attenti
- The - Provid on of
pati ea pain
ent comfo - To
repo rtable avoid
rt positio an
that n emph
pain asis
is on the
relie area
ved of
and - Provid injury
cont ea pain
rolle peace - To
d ful lessen
enviro the
nment irritabi
lity of
the
DEPENDENT patien
: t
- Give
medic
ation - To
as ease
prescr the
ibed pain
by the
physic
ian(su
ch as
analg
esic)
COLLABORA
TION:
- Monit
or the
xray - To
and know
ultras what
ound is the
test reaso
n of
pain