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Far Eastern University

Institute of Nursing

Student Nurse In –Charge: Student Head Nurse: LEOCHICO, Maricris M.

Patient: Alfredo, Martinez Date: 12/14/2010
Room and Bed No.: 506 Bed D
Nursing Analysis Goals and Intervention Rationale Evaluation
Diagnosis/Cues Objectives
Acute pain related Definition: Goal:
to biological injuring Unpleasant sensory After 3 day of Independent:
agent and emotional nursing ♥ Encourage ♥ Promotes The outcome was
experience arising interventions, the patient to cooperation achieved the
Subjective: from actual or patient will report verbalize from the client reported
S>: “Masaki tang ulo potential tissue that pain is relieved about pain. client. that the pain was
ko mga tatlong araw damage or or controlled. (Fundament relieved.
na ito.” described in terms als of
S>: “Kaninang of such damage. Objectives: Nursing by
umaga inatake na (International • After 2 hours of Taylor 5th e.
naman ako” Association for the discussion, the ♥ Provide p.1216)
study of pain). patient will comfort ♥ This
Objective: Sudden or slow demonstrate use measures calms and
O>: The client was onset of any of relaxation such as deep soothes the
massaging his head intensity from mild skills and breathing patient.
every now and then. to severe with an diversional exercises. (Fundament
O>: The patient anticipated or activities, as als of
seems irritable. predictable end and indicated, for Nursing by
O>: Facial mask duration of less individual ♥ Encourage Taylor 5th e.
than 6 months situation. diversional p.1216)
Measurement: • After 2 hours of activities
M>: The client rated Background theory: discussion the (TV/radio,
the pain as 9 in the According to patient will, socialization ♥ To divert
scale of 1 to 10 where Melzack and Walls verbalize non
10 is the highest and gate control theory pharmacologic with others, attention
1 is the lowest. (1965), peripheral methods that imagery) from pain.
nerve fibers provide relief. (Fundament
carrying pain to the • After 2 hours of als of
spinal cord level discussion, the Nursing by
before transmission patient will Taylor 5th e.
to the brain. follow p.1216)
Synapses in the prescribed ♥ Provide
dorsal horn acts as pharmacological therapeutic
gates that close to regimen. touch.
keep impulses from
reaching the brain ♥ To
or open to permit promote
impulses to ascend feeling of
to the brain. comfort.
♥ Monitor Vital and Child
signs. Health
Nursing 5th e.
by Pilliteri
page 547)

♥ An
Collaborative: (Manual of
♥ Administer Nursing
(analgesic) as Procedures
ordered. Vol. I by
and Lontoc
page 122)

♥ To
comply with
order to
relieve pain
(Manual of
Vol. II
Mejilla and
Merin. page