Patient’s Name: Clinial Instructor:

Date:
Age: Sex: Clinical area:
Diet:
Medical Diagnosis: Room #:
Physician:

SUBJECTIVE OBJECTIVE NURSING SCIENTIFIC PLANNING INTERVENTIO RATIONALE EXPECTED

DIAGNOSIS REFERENCE NS OUTCOME
 INDEPENDEN
“Sakit -expressive Acute Pain related That after 8 T -to gain trust After 4 hours
gamay behavior secondary to hours of -establish of nursing
akong such as Surgical Operation Nursing rapport intervention,
tiahian pag restlessness, Intervention, - to encourage patient was
mugimok irritability patient will -emphasize patient not to able to:
ko” as and sighing Definition: be able to: ordered diet eat untolerated
verbalized Unpleasant food -Report pain is
by the -impaired sensory and -Report pain relieved/
patient physical emotional is relieved/ -to note if controlled
mobility experience arising controlled - Monitor vital -demonstrate
there are
from actual or - signs the use of
changes in
-facial potential tissue demonstrate vital signs relaxation
grimacing damage or the use of skills and
when in pain described in terms relaxation diversional
of such damage; skills and - To satisfy the activities, as
-Provide
-disturbed sudden or slow diversional confinement indicated, for
comfort
sleep pattern onset of any activities, as of patient individual
measure
intensity from mild indicated, for situation
-with the pain to severe with an individual - To inhibit -verbalized
scale of 6, as anticipated or situation pain nonpharmacol
0 as the predictable end -verbalized -Encourage ogic methods
lowest and and duration of nonpharmac deep breathing that rovide
10 as the less than 6 ologic relief.
highest months. methods
that rovide
relief. -Provide safety
-To prevent
measure
-V/S Source: from injury

T- Doenges, -Develop
- To alter pain
M.E.,Moorhouse, communication
and diminish
P- M.F.,&Murr,A.C. emotional
R- (2008). Nurses stress
pocket guide:
BP- Diagnosis -review
prioritized
interventions and procedures/exp - To reduce
rationale (8th ed). ectations and concern of
Philadelphia, tell client when unknown and
Pennsylvania: F.A. treatment will associated
Davis Company. hurt muscle tension

DEPENDENT

-Administer - To reduce
analgesics as concern of
indicated to unknown and
maximal associated
dosage as muscle tension
needed