Inandan. V Fortunato Alfredo B.

NCP

Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective: Acute pain related to After 5 hours of Independent: After 5 hours of

 Patient hooked protective gestures nursing intervention  Assess for  To help nursing intervention
to nasogastric and motion to The patient will: referred pain determine the patient was able
tube. position to avoid pain possibility of to meet the goals
 Patient hooked with facial grimace. Short term: underlying with and evidence of
to IV and Foley condition or the absence of the
catheter Report pain is organ signs and symptoms
 Hooked to BP relieved or dysfunction related to pain.
monitor controlled. requiring
 Hooked to ECG treatment.
 Hooked to pulse Long term:  Observe  Observations
Oximetry nonverbal cues may not be
 Facial grimace is Be free from any and pain congruent with
evident signs and symptoms behaviors. verbal reports or
 Patient makes related to pain and may be only
gestures and irritation indicator present
motions to when client is
nasogastric tube unable to
 Teary eyed verbalize.

Vital signs : Dependent:

BP: 130/80  Administer  Antibiotics will
RR: 22 anitbiotics help kill and stop
Sp02: 98 ordered by the proliferation
HR: 92 doctor. of the bacteria
T: 36.4 which could
cause infection.
Collaborative:
 Suggest visitor to  To provide
visit patient comfort
 Provide comfort  To promote non
measures pharmacological
pain
management