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Palma, Eman Faulyn H.

BSN 4C

Assessment Nursing Diagnosis Scientific Analysis Plan of Care Implementation Rationale Evaluation

Subjective:May sakit pa din

akong

nararamdaman.

Objective:

-Observed

evidence of pain

-Guarding

behavior

-Restlessness

-Facial mask ofpain.

-Narrowed

focusing

-Self-Focusing

Measurement:

BP: 140/100

Temp: 36.7

RR: 22PR: 75

Acute Pain relatedto inflammation

and distortion of

tissues as

evidenced by

patients

verbalization of

biliary colic, facial

mask of pain,

guarding

behavior,

autonomicresponses, self

focusing,

narrowed focus

and high BP.

Pain is anunpleasant

sensory and

emotional

experience arising

from actual or

potential tissue

damage or

described in terms

of such damage.

Short term:After 4 hours of

nursing

interventions,

patients pain will

be controlled with

the use of

relaxation skills.

Long term:

After 5 months of

series nursinginterventions with

collaborations

with the physician

and other health

care agents,

patients disease

will be cured as

manifested by

patients pain

relived,homeostasis

achieved and

complications are

minimized.

Safety&Quality:1.Keep the side

rails raised.

Management of

Resources and

environment:

2.Provide a cool

or normal

temperature

environment.

Health Education

3.Discuss to client

the description of

her disease and

what factors to

avoid and what

things to do.

Ethico-MoralResponsibility

4.Make sure to

respect clients

rights as an

individual or

group.

1.Due to the

restlessness of

client, client

should be safe to

avoid falls and

injury.

2.For the client to

feel comfortable

even when the

client is in pain.

3.For the client to

be knowledgeable

about her

condition.

4.Its an obligationof the nurse to

respect whatever

the clients

decision is. Nurses

have no right to

interfere with

whatever decision

the clients make

After 4 hours ofnursing

interventions, the

patients pain is

controlled with

the use of

relaxation

methods and

techniques.

After 5 months ofseries of nursing

interventions with

collaborations

with the physician

and other health

care agents, it is

expected that the

clients disease is

cured as

manifested bypatients pain

relived.

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Legal

Responsibility:

5.Collaborate in

treatment of

underlying

condition

processes causing

pain and proactive

management of

pain.

Personal and

Professional

Development

6.Assess clients

learning needs,

assess clients

knowledge of and

expectations

about pain

management.

Research

7.Provide comfortmeasures and

encourage use of

relaxation

techniques such

as focused

breathing or

distract attention

by listening to

5.To assist client

to explore

methods to

control pain.

6.To identify if

knowledge needsof client.

7. To reduce

tension and

distract clientsattention to pain.

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music.

Records

Management

8. Make sure to

observe

confidentiality

and privacy in

keeping and

documenting

clients records.

Communication

9.Make sure to

encourage client

to alwaysverbalize what

she feels.

Collaboration and

Teamwork

10.Discuss to

family the impact

of pain on lifestyle

or independenceand ways to

maximize level of

functioning.

8.Because it is

known as legal act

and it should be

practiced by

nurses.

9.To establish

rapport, trust, and

let client feel

confident

whenever thenurse is around.

10.To establish

cooperation from

the clients family

in helping in

promoting

wellness of theclient.

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Quality

Improvement

11.Evaluate and

document clients

response to

analgesia, and

therapeutic

measures

provided ,and

assist in

transitioning

based on

individual needs.

11.To be able to

measure

improvement of

condition of

client.