Amabel U.
Cortez (G4A) March 1, 2019
Mary Mediatrix Medical Center Head Nurse: Jose Marco B. De Castro
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Acute pain After 2 hours of Independent: Goal met. After
related to nursing 2 hours of
“Nasakit pa din yung chemical burn interventions, Assess pain These data can be used nursing
tyan ko kapag of gastric the patient will characteristics to identify the extent of interventions,
nagalaw ako ng mucosa verbalize relief (quality, severity, the pain as well as the patient
biglaan” from pain and location, onset, serve as a baseline verbalized relief
rate it as 2/10 duration, precipitating information. from pain and
Objective: from 7/10. and relieving factors). rated it as 2/10
Restless from 7/10.
Observe or monitor
Pacing Some people deny the
signs and symptoms
Rigid experience of pain
associated with pain,
abdomen when it is present.
such as BP, heart
Self- Attention to associated
rate, temperature,
focused signs may help the
color and moisture of
Wrinkled nurse in evaluating
skin, restlessness,
nose pain.
and ability to focus.
Raised
upper lips Assess for probable
Rapid
cause of pain.
breathing
Rated pain Different etiological
as 5/10 in factors respond better
Assess patient’s
a pain knowledge of or to different therapies.
scale of 0- preference for the
10 array of pain-relief
strategies available. Some patients may be
unaware of the
effectiveness of
nonpharmacological
methods and may be
willing to try them, either
with or instead of
traditional analgesic
medications. Often a
combination of therapies
(e.g., mild analgesics
· Assess patient’s with distraction or heat)
willingness or ability to may prove most
explore a range of effective.
techniques aimed at
controlling pain.
Some patients will feel
uncomfortable exploring
· Anticipate need for alternative methods of
pain relief. pain relief. However,
patients need to be
informed that there are
multiple ways to manage
pain.
· Respond immediately to
complaint of pain. One can most effectively
deal with pain by
preventing it. Early
intervention may
decrease the total
amount of analgesic
required.
In the midst of painful
experiences a patient’s
perception of time may
· Eliminate additional become distorted.
stressors or sources Prompt responses to
of discomfort complaints may result
whenever possible. in decreased anxiety in
the patient.
Demonstrated concern
for patient’s welfare
and comfort fosters the
development of a
· Encourage small, trusting relationship.
frequent meals
Patients may experience
· Identify and limit
an exaggeration in pain or
foods that cause
a decreased ability to
discomfort such as
tolerate painful stimuli if
spicy foods and
environmental,
carbonated drinks.
intrapersonal, or
· Encourage to assume intrapsychic factors are
position of comfort. further stressing them.
Dependent:
Small meals prevent
· Administer analgesic distention and gastrin
for relief of pain (e.g. release.
morphine sulfate).
BAUTISTA, Jesther Rowen, SN IV
Food has acid
· Administer antacids neutralizing effect and
(e.g. Magnesium dilutes gastric content.
Hydroxide Aluminum
Hydroxide)
Reduces abdominal
tension and promotes
sense of control.
Relieves abdominal
pain by reducing the
peristaltic activity.
Helps relieve pain by
neutralizing stomach acid
and increasing
bicarbonate and mucus
secretion.
Collaborative: Patient may receive
nothing by mouth initially.
· Provide and implement
When oral intake is
prescribed dietary
allowed, food choices will
modifications.
depend on the
