ASSESSMENT

PROBLEM: Pain

NURSING DIAGNOSIS

PLANNING

INTERVENTION RATIONALE

EVALUATION

Pain related After the Monitor vital For to spinal thorough signs baseline Subjective cue: fusion with nursing care data. maglisod kog instrumentati the patient Assess the Adequate lihok kay sakit sa on will verbalize level of pain pain likod, as an adequate and initiate manageme verbalized by the level of pain nt allows patient. comforts or management for faster Objective cue: show strategies as healing and Received absence of soon as more patient lying pain possible. cooperative on bed, behavior patient. conscious, within 1hour coherent and of a specific Use non Alternative responsive; nursing pharmacologi treatment without IV. intervention. c pain also Good skin management interrupt turgor techniques, the pain Grimace noted such as stimulus when moving. imagery, and provide With the pain relaxation, relief. Non

scale of 9. Vital signs taken: TPRBP-

touch, music, application of heat and cold compress.

Document pain assessment interventions and the patient reactions.

Perform pain assessment each time pain occurs. Note and

pharmacolo gic methods can be affective adjunct to pain manageme nt. Proper documenta tion guides the selection of the most effective means of pain control. To rule out worsening of underlying condition/

investigate developme changes from nt of previous complicatio reports. n. Reassure the Realistic patient that expectation some decrease discomfort is anxiety and expected and give the that a variety patient a of measure sense of can be tried control. to reduce discomfort. Provide quiet To prevent environment, increase calm stimuli. activities. Encourage To prevent adequate fatigue rest.