Republic of the Philippines
ISABELA STATE UNIVERSITY
Ilagan City, Isabela
COLLEGE OF NURSING
ASSESSMENT NURSING PLANNING IMPLEMENTATION EVALUATION
DIAGNOSIS INTERVENTION RATIONALE
Subjective Acute Pain related to Short Term Goal: Independent Independent Short Term Goal:
Mediyo masakit pa siya Post-operative Physical 1. Monitor vital sign 1. To monitor. Base
kapag nagagalaw at injury agent as evidence After an hour of 2. Provide comfort line After an hour of
kapag nalalamigan As by facial grimace and rendering nursing measure such as use of data and check for the rendering nursing
verbalized by the guarding behavior intervention. The patient heat pack. response in intervention. The patient
patient. will be able to show 3. Advised SO to. interventions. was able to show
improvement on the Reposition patient every 2. The use of non improvement on the
Pain scale: 5/10 pain level as evidence 2 Hours. Pharmacologic pain level as evidence
by pain scale 2/10 , the 4. Increased fluid intake technique to relieve by pain scale 2/10 , the
patient will be able to and provide quite and pain. patient will be able to
Objective verbalized clean environment 3. To avoid bed sore verbalized
: Facial grimace upon understanding on the use 5. Note location of and understanding on the use
palpating of non-pharmacologic surgical procedures. Pneumonia. of non-pharmacologic
: dry and cold skin technique to relieve 6. Encourage adequate 4. For hydration and technique to relieve
: Guardinng behavior pain. rest quite and clean pain.
7.Encourage relaxation environment is essential
VS taken as follows: Long Term Goal: technique(ex: music and for recovery. Long Term Goal:
o BP – 130/80 deep breathing). 5. As this can influence
o RR –25cpm After 8 hours of nursing 8.Determine factors in the amount of After 8 hours of nursing
o PR –89bpm intervention, the patient client’s lifestyle postoperative pain intervention, the patient
o O2Sat – 99% will be able to report experienced. was able to report pain
o Temp – 36.4 pain is 6. To avoid fatigue. is relieved/controlled,
relieved/controlled, free 7. To distract attention free from discomfort
from discomfort and Dependent: and reduce tension. and regained body
regained body strength. 1. Administer 8. that can affect strength.
analgesic as ordered. responses to analgesics
2. Administer pain Dependent Goal met.
reliever as ordered 1. To relieved pain
such as celecoxib. 2. To relieved pain and
reduce inflammation.
ISABELA STATE UNIVERSITY
Ilagan City, Isabela
COLLEGE OF NURSING
ASSESSMENT NURSING PLANNING IMPLEMENTATION EVALUATION
DIAGNOSIS INTERVENTION RATIONALE
Subjective Acute Pain related to Short Term Goal: Independent Independent Short Term Goal:
Mediyo masakit pa siya Post-operative Physical 1. Monitor vital sign 1. To monitor. Base
kapag nagagalaw at injury agent as evidence After an hour of 2. Provide comfort line After an hour of
kapag nalalamigan As by facial grimace and rendering nursing measure such as use of data and check for the rendering nursing
verbalized by the guarding behavior intervention. The patient heat pack. response in intervention. The patient
patient. will be able to show 3. Advised SO to. interventions. was able to show
improvement on the Reposition patient every 2. The use of non improvement on the
Pain scale: 5/10 pain level as evidence 2 Hours. Pharmacologic pain level as evidence
by pain scale 2/10 , the 4. Increased fluid intake technique to relieve by pain scale 2/10 , the
patient will be able to and provide quite and pain. patient will be able to
Objective verbalized clean environment 3. To avoid bed sore verbalized
: Facial grimace upon understanding on the use 5. Note location of and understanding on the use
palpating of non-pharmacologic surgical procedures. Pneumonia. of non-pharmacologic
: dry and cold skin technique to relieve 6. Encourage adequate 4. For hydration and technique to relieve
: Guardinng behavior pain. rest quite and clean pain.
7.Encourage relaxation environment is essential
VS taken as follows: Long Term Goal: technique(ex: music and for recovery. Long Term Goal:
o BP – 130/80 deep breathing). 5. As this can influence
o RR –25cpm After 8 hours of nursing 8.Determine factors in the amount of After 8 hours of nursing
o PR –89bpm intervention, the patient client’s lifestyle postoperative pain intervention, the patient
o O2Sat – 99% will be able to report experienced. was able to report pain
o Temp – 36.4 pain is 6. To avoid fatigue. is relieved/controlled,
relieved/controlled, free 7. To distract attention free from discomfort
from discomfort and Dependent: and reduce tension. and regained body
regained body strength. 1. Administer 8. that can affect strength.
analgesic as ordered. responses to analgesics
2. Administer pain Dependent Goal met.
reliever as ordered 1. To relieved pain
such as celecoxib. 2. To relieved pain and
reduce inflammation.
