Name of Patient: Elenita Gulpa

Chief Complaint: Pain

Age: 24 days old

Room/Ward: Surgery OPD Clinic

Date/time

Cues

Needs

July 16 2015
73 Shift
09:30 AM

Subjective:
Sakit akung
tutoy dugay
na man ni
pero
gina
antos na lang
nako

H
E
A
L
T
H

Objective:
Pain
rated
6/10
as
pain scale
irritability
Facial
grimaces
Distraction
behavior

P
E
R
C
E
P
T
I
O
N
A
N
D
M
A
N
A
G

Nursing
diagnosis
Acute Pain
related
to
disease
process as
evidenced
by reports
of pain

Objectives
Within 1 hour
of
nursing
intervention,
the
patient
will be able
to
show
reduced pain
as evidenced
by

Nursing intervention
1. Assess the level of pain, location and
scale of pain, perceived patient
Rationale: Knowing the level of pain that is
felt so it can help determine appropriate
interventions.

2. Provide optimal pain relief with analgesics

as prescribed by the doctor.
Rational: analgesic drugs block the pain
Source:
receptors so that the pain can not be
Carpenito-decrease rate perceived. Each client has a right to expect
Moyet,
of pain scale
maximum pain relief. Optimal pain relief
L.J.2010.Ha
using analgesics includes determining the
ndbook of -calm facial preferred route, drug, dosage, and frequency
Nursing
expression
for each individual. Medica-tions ordered on a
Diagnosis.1
prn basis should be offered to the client at the
th
3
interval when the next dose is available
Ed.Pp.5254.
3. Consider cultural influences on pain
response (e.g., cultural beliefsabout pain may
result in a stoic attitude)
Rationale: Each person experiences and
expresses pain in an individual manner using
a variety of sociocultural adaptation
techniques
4. Observation of vital signs every 4 hours

Evaluation

E
M
E
N
T

Rationale: Changes in vital signs, especially

temperature and pulse rate is one indication of
increased pain experienced
5. Reduce or eliminate factors that precipitate
or increase pain experience (e.g., fear, fatigue,
monotony, and lack of knowledge).
Rationale: Personal factors can influence pain
and pain tolerance. Factors that may be
precipitating or augmenting pain should be
reduced or eliminated to enhance the overall
pain management program
6.Eliminate additional stressors or sources of
discomfort whenever possible
Rationale: Patients may experience an
exaggeration in pain or a decreased ability to
tolerate painful stimuli if environmental,
intrapersonal, intrapsychic factors are further
stressing them
7. Teach the use of nonpharmacologic
techniques (e.g., relaxation, guided imagery,
music therapy, distraction, and massage)
before, after, and if possible during painful
activities; before pain occurs or increases; and
along with other pain relief measures
Rationale: The use of noninvasive pain relief

measures can increase the re- lease of

endorphins and enhance the therapeutic
effects of pain relief medications.
8. Respond immediately to complaint of pain
Rationale: in the midst of painful
experiences, a patients perception of time
may become distorted. Prompt responses no
complaints may result in decreased anxiety.
Demonstrated concern for the patients
welfare and comfort fosters the development
of a trusting relationship.
9. Assist patient in a comfortable position
Rationale: a comfortable position to avoid an
emphasis on the area of injury / pain.

10. Provide rest periods to facilitate comfort,

sleep, and relaxation.
Rationale: The patients experiences of pain
may become exaggerated as the result of
fatigue. In a cyclic fashion, pain may result in
fatigue, which may result in exaggerated pain
and exhaustion. A quiet environment, a
darkened room, and a disconnected phone are
all measures geared toward facilitating rest