REPUBLIC of the PHILIPPINES

City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
CENTER OF NURSING
J.P. Rizal Extension, West Rembo Makati City 1215
Telephone No.: (+632) – 881 – 1571

Name of student: ____________________________ Year/Group:_______ Concept: __________________________ Area:___________________

Name of Patient:_____________________________ Clinical Impressions/Diagnosi:________________________________________Age:______ Chief complaint: _____________________

ASSESSMENT NURSING DIAGNOSIS INFERENCE PLANNING NURSING INTERVENTION RATIONALE EVALUATION

Subjective Acute pain related Long Term Independent: Independent: Long Term:
Cues to post- surgical Ectopic Objective  Perform a comprehensive  To assess Goal Met.
“Masakit po yung tahi incision as Pregnancy After 6 hours of assessment of pain etiology/precipitating After 6 hours of nursing
sa may left side ng evidenced by pain nursing intervention to include location, contributory factors. intervention the client
tiyan ko po sa may scale of 8/10 the client will characteristics, verbalized alleviation of
baba pag gumagalaw” Rupture of fallopian verbalized onset/duration, pain with a pain scale of
As verbalized by the tube alleviation of pain frequency, quality and severity 3/10.
patient with a pain scale of and precipitating and  To evaluate client’s
3/10. aggrevating factors. response to pain
Objective Cues Reference: Surgery  Accept client’s description of Short Term Objective
 Post-surgical Short Term pain and acknowledge the  For accurate data After 30 minutes of
incision at the Nurse’s Pocket Objective pain experience and convey base nursing intervention the
left lower Guide: Diagnoses, Wound After 30 minutes of acceptance of client’s client
abdomen Prioritized nursing intervention response to pain.  To provide non demonstratedtechniques
 Pain Intervention and the client will  Monitor vital signs pharmacological pain to alleviate pain such as
scale:8/10 Rationales Post-Surgical incision demonstrate management deep breathing
(when moving) By: Marilynn E. Local pain techniques to  Provide and educate client exercises, imagery
 Facial grimace Doenges, Mary alleviate pain such comfort measures (e.g.,back  To assist client to diversion and use of hot
 Restlessness Frances Reference: as deep breathing rub,change of position, use of explore methods for and cold compress.
Moorhouse, Alice Reference:Brunner exercises, imagery heat/cold)
 Irritability C. Murr,pg. 388- &Suddarth’s diversion and use of  alleviation/ control of
392 Textbook of Medical- hot and cold  Instruct in/encourage use of pain.
SurgicalNursing 11 compress. relaxation exercises, such as
th focused breathing, diverting
editionby Smeltzer, attention with the use of Dependent:
Bare,Hinkle, Cheeve imagery.  To assist client to
Dependent: explore methods for
 Administer analgesics as alleviation/control of
indicated to maximal dosage pain.
as needed to maintain
“acceptable” level of pain.  To promote
Notify physician if regimen is Independent to client
inadequate to meet pain for self-
control goal. administration.
 Demonstrate/monitor use of
self-  To provide comfort
administration/clientcontrolle and lessen the
d analgesia (PCA). discomfort of the
 Assist client to alter drug patient
regimen,based on individual
needs. Increasing/decreasing
dosage, stepped program
(switching from injection to
oral route, increased time
span as pain lessens) helps
in self-management of pain.

Collaborative: Collaborative:
.
 Provide for individualized To promote
physical therapy/exercise appropriate physical
program that can be therapy and exercise.
continued by the client when
discharged.