Assessment Nursing Planning Nursing Rationale Evaluation

Diagnosis Intervention
Subjective Data: Acute After 30 Independent: After 30
pain minutes of minutes of
“Sumasakit po yung  Obtain client  To rule out
related to nursing nursing
inoperahan sa akin” assessment worsening of
surgical intervention intervention
as verbalized by the to pain underlying
incision s, the s, the patient
patient condition/
patient will reported that
development
report pain pain is
of
is controlled as
Objective Data: complication
controlled  Provide evidence by
s
 Pain scale: as evidence comfort pain scale
8/10 by pain measures 3/10
scale 3/10  To promote
 Expressive (e.g. touch, nonpharmac
behavior repositioning ologic pain
(moaning) , nurse’s management
 Distraction presence),
Behavior quiet
(seeking out environment
other people) and calm
activities
 To distract
 Instruct in/
attention and
encourage
reduce
use of
tension
relaxation
technique
such as
focused
breathing,
imaging.
 Encourage
having
adequate rest
 To prevent
period.
fatigue

Dependent
 Administer
Analgesic
 To maintain
acceptable
 level of pain.
Notify
physician if
regimen is
inadequate to
 Evaluate/ meet pain
Document control goal.
Client’s
response to
analgesia,  Increasing/
and assist in decreasing
transitioning/ dosage,
altered drug stepped
regimen, program
based on helps in self-
individual management
needs. of pain.