ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
● Acute pain related Independent ● After 4 hours of
Subjective Data: to surgical Short Term: nursing intervention
procedure as ●Instruct the ●To reduce pain the patient’s pain
“Nasakit padin ang evidenced by pain ●After 4 hours of patient to continue especially when scale was decreased
tahi ko hanggang scale of 7/10 nursing intervention to use the binder. moving. from 7 to 4.
likod” as verbalized the patient’s pain
by the patient. scale will decrease
from 7 to 4. ●Provide comfort ●To promote
●Pain scale of 7/10. measures such as, nonpharmacological ●After 6 hours of
touch, pain management. nursing interventions
repositioning, calm the patient was
Long Term: activities. reported pain is
Objective Data: controlled.
● After 6 hors of
●Limited movement nursing intervention ●Instruct patient to ●To destruct
the patient will use relaxation attention and reduce
●Facial grimace report pain is techniques and tension.
controlled. encourage
●Observed evidence diversional activity
of pain such as listening to
music, watching TV
and socialization
with others.
●Encourage patient
to do deep ●It can help to
breathing exercise. reduce pain and
discomfort by
promoting relaxation
and relaxing
endorphins which
are natural pain
killers.
Dependent
● Administer pain
reliever as
prescribed by the
physician. ● To reduce pain
pharmacologically.
Collaborative
●Collaborate with
the physician if the ●To accurately
pain is worsened. assess the
underlying cause
and adjust the
treatment plan.