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Assessment Diagnosis Planning Intervention Rationale Evaluation

Acute back pain After 8 hours of Independent:


related to pressure nursing -Assessed pain, - Pain assessment
on lumbar nerve interventions, character, can provide clues
endings secondary the location, severity, about diagnosis, and
to enlargement of patient will be and duration; used be used to determine
the outpouching able to a pain rating treatment required
abdominal aortic experience scale.
aneurysm gradual - Accepted client’s - Pain is subjective
reduction / relief description of experience and
of pain from a pain. Acknowledged cannot be felt by
pain scale of 8 the pain experience others.
to at least 4. and convey
acceptance of
client’s response
to pain.
- Monitored v/s - Slight increase of
every 4hrs. RR could be resulted
from the possibility
of patient’s
reaction towards
pain.
- Review client’s - May be helpful for
previous management pain
experiences with control.
pain and methods
found in the past.
- Teach client and - To maximize opportunities
significant other about the for self-control over pain
non-pharmacologic ways manifestations.
to lessen the pain.
- Instruct client to report - Only the client can
any judge the level and
improvement/exacerbation distress of pain. This is to
in pain experience. provide appropriate nursing
intervention if necessary.
Dependent:
- Administer medications,
particularly analgesics, as
prescribed.