Assessment Nursing Planning Interventions Rationale Evaluation

Diagnosis
Subjective: Acute Pain Short Term: - Evaluate pain - Provides GOALS MET
- “ang sakit ng tahi related to tissue After 8 hours of noting baseline
ko” trauma as nursing characteristics, information for
evidenced by intervention, the location, and effectiveness of
complaints of patient will intensity. interventions.
Objective: pain, facial report decreased
grimacing and pain sensations,
BP - 130/90 irritability. with a pain rating - May indicate
PR - 110 of not more than - Assess vital pain and
RR - 26 2/10. signs, noting discomfort.
T° - 37.2 °C tachycardia,
- Facial Grimacing Long Term: hypertension and
- Weak and pale in After 2 days of increased
appearance nursing respiration. - Discomfort can
-moderately irritable intervention, the be
-pain scale of 6 patient will - Assess causes caused/aggravate
report absence of of possible d by the presence
pain, appears discomfort other of contruptions,
relaxed, able to than perineal gastric gas, and
rest/sleep and wound. bladder pain.
participate in
ADL.
- May relieve pain
and enhance
- Reposition circulation
patient (Semi relieves muscle
Fowler’s, Lateral tensions and
Sim’s). pressures.

- Pain medication
- Administer for relief.
medication as
prescribe.
- Relieves muscle
and emotional
- Encourage use tension,
of relaxation enhances sense
technique. e.g. of control and
Deep Breathing may improve
Exercises coping abilities.