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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Acute pain r/t STG: 1.) Instruct in use of > To provide comfort STG:Partially met
“Ang sakit ng tissue trauma and After 1 hour of nursing relaxation exercises such After 1 hour of nursing
inoperahan saakin.” le fort II fracture intervention, the as pursed lip breathing intervention, the patient was
As verbalized by the on the skull aeb patient will be able to: able to:
> Pain is subjective
pt. “Masakit tuwing 2.) Perform comprehensive experience and must be
1. Demonstrate use of 1. Pt. demonstrate use of
nagagalaw ang assessment each time pain described by client in order
relaxation skills and deep breating excerxises
Objective: muka ko at pag diversional activities occurs whenever he feels pain as
to plan effective treatment
*c guarding hindi nagalaw well as talking to his s.o to
behavior on the face nakirot.” as 2. Report slightly or divert his attention away
*c facial grimace verbalized by the 3.) Provide back rub or > To provide comfort and
totally relieved by from the pain
*c titanium and pt. and pain scale verbalizing pain scale position the client to her relaxation
screws on the le fort of 8/10 (10 being from 10 to 6 comfortable position 2. “Siguro mga 6/10 na
II area of face the highest) ngayon.” as verbalized by
*c swelling on face 3. Shows less or no 4.) Create a quiet and non > To divert the attention the pt.
guarding behavior disruptive environment from pain
3. Pt. still show guarding
LTG: behavior towards his face
5.) Administer analgesic as >To inhibit synthesis of
After 2-3 days of
nursing intervention, ordered (Collaborative) prostaglandin LTG:Met
the patient will be able After 2-3 days of nursing
to: 6.) Encourage diversional intervention, the patient will
activities such as reading be able to:
>Provide comfort and
1. Shows sign of her favorite pocketbooks
healing in the incision or socialize with others relaxation for the client 1. Shows sign of healing in
site the incision site, face appears
7.) Encourage adequate less swollen
2. Reports relieve rest periods > To prevent fatigue
from pain and 2. “Hindi na masyadong
verbalize feeing of masakit and opera ko.” as
comfort verbalized by the pt.