ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Acute pain at right After 1 to 2 hours of Independent Goal met.

“Nagsakit toy sugat upper quadrant related nursing interventions,  Assess and monitor vital  To have a baseline data After 1 to 2 hours of
ko” as verbalized by to disruption of tissues the client will be able signs nursing interventions, the
the patient. secondary to operative to report relief from  To confirm signs of client was able to report
procedure as pain and pain scale  Assess incision site inflammation and relief from pain and pain
Pain scale of 7/10 manifested by will be reduced from infection scale was reduced from
subjective complain of 7/10 to 2/10. 7/10 to 2/10.
Objective: pain and positive  Provide rest periods.  To facilitate comfort and
Facial grimacing guarding behavior and maximize energy
Guarding behavior grimacing. production

Vital Signs taken as  Position client  Proper positioning

follows: comfortably in bed. provides comfort to the
patient.
BP:150/90 mmHg
PR: 90bpm
RR: 17 breaths per  Encourage use of  Helpful in alleviating
minute relaxation techniques such anxiety and refocusing
Temp: 36.4 ̊ C as deep breathing attention which can
O2 Sat: 97% relieve pain

Dependent:
 Administer pain  To reduce pain and
medications as ordered. promote comfort