Patients Name: Banilad, Arvin Age/ Sex: 14/M Diagnosis: MHI sec !

A Instit"tion: SPM# Diagnosis/#"e Acute Pain on Right Shoulder r/t physical trauma as manifested by guarding behavior and facial grimace SUBJEC !"E CUES# verbali$ed %Sa&it &aayo a&ong abaga dili na&o gusto iliho&'( )BJEC !"E CUES# Rated pain as * out of +, -acial grimace .urading behavior /01 # 2*'* <emonstrate use of diversional activities @' provide calm and Auiet environment /adBust lights7 temperature and eliminate Nee d P 3 4 S ! ) 5 ) . ! C Desired o"tcomes After 6 hours of nursing interventions7 the patient 8ill be able to9 .eneral# Become relieved of signs and symptoms of pain e:perienced as evidenced by# Specific# "erbali$e pain is relieved /rate pain from ,;6 out of +,1 N"rsing Intervention !=<EPE=<E= +' assess contributing factors to pain /noise7 8rong positioning7 environment1 >' revie8 medication regimen 2' as& client to rate pain on ,; +, scale /rated as ? out of +,1 6' provide comfort measures such as repositioning the client in a comfortable position and providing a hot or cold compress +' to determine underlying cause of pain and treat accordingly' >' certain drugs may fatigue and dro8siness' cause $ationale %val"ation statement

2' to assist in evaluating impact .oal unmet' Patient of pain on clientCs life' verbali$ed %Sa&it gihapon a&ong abaga7 di gihapon na&o iliho&'( 6' to allo8 nonpharmocological pain relief and promote good circulation to the brain and decrease vasoconstriction .oal met' Patient 8as able to rela: by utili$ing bed rest and deep breathing'

P# D> bpm R# >+ cpm BP# ++,/D, mm3g BACE.R)U=< E=)F5E<.E# Acute pain is an unpleasant sensory and emotional e:perience arising from actual or potential tissue damage or described in terms of such damage9 sudden or slo8 onset of any intensity from mild to severed 8ith an anticipated or predictable end and a duration of less than * months' S)URCE# =urseCs Poc&et .uide# <iagnoses7 prioriti$ed interventions and rationales ++th Ediction by Garilynn <oenges Brunner and SuddarthCs e:tboo& of Gedical; Surgical =ursing ++th

such as rela:ing and/or sleeping

offensive odors 8hich may contribute to headache1 *' instructe in rela:ation techniAues /deep breathing7 imagery1

@' to decrease environmental factors 8hich contribute to migraine and promote rest' .oal met' Patient 8as able to sleep for 6 hours straight and felt rested after8ards' *' to distract attention from pain and decrease tension .oal met' Client 8as able to use deep breathing and reported pain relief D' to conserve energy of the after8ards' patient and prevent fatigue

Rest and feel rested after adeAuate rest interval

D' encrourage adeAuate rest periods

Utili$e non; pharmacological methods of pain relief / deep breathing7 guided imagery7 etc1 Be able to perform A<5s as tolerated

H' assist in self;care activities as tolerated

?' provide peaceful Iand adeAuate resting environment /dim lights7 adBust temperature7 8rin&le;free bed7 Auiet surroundings1 C)55AB)RA !"E# +' administer medications as ordered by physician /analgesics7 etc1

H' o promote client .oal met' Client 8as able to independence as much as possible perform A<5s 8ith minimal and acAuire sense of function assistance from 8atchers /feeding7 self;care7 etc1 ?' to enhance Auality sleep and promote rest 8hich harnesses energy for future use'

Edition by Su$anne C' Smelt$er >' encourage 8atchers to assist patient during diversional activities /minimi$e noise7 allo8 client to verbali$e feelings and promote rest and sleep1

+' medications 8ill provide synergistic effect 8ith nonphramacologic interventions for pain relief and promote better circulation by aiding in vasodilation for better blood flo8 to the brain and altering prostaglandin synthesis to decrease pain >' the significant others &no8 the client more and 8ill be able to aid in diverting clientCs attention from pain'