ASSESTMENT NURSING SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION

10-28-09 DIAGNOSI EXPLANATION INTERVENTION

S
Subjective: Acute Injury on the SHORT TERM • Establishe • To gain SHORT TERM GOAL:
• “Masakit pain skin and GOAL: d rapport trust and Goal partially met as
itong sugat related to tissue Within 30 mins-1 cooperati evidenced by:
ko,lalo na damage (trauma) hou hours of • Take vital on of • Pain rated 4/10
kapag of skin & ↓ nursing signs patient from 6/10
gumagala tissue 2⁰ Release of intervention, the • For • Demonstrated:
w ako” to chemicals patient will be • Evaluated baseline – Deep breathing
surgical such as able to: regularity data – Splinting with
OBJECTIVE: procedur prostaglandin • Verbalized noting the pillow
• Verbalized e done. and pain relief characteri • Helps – Slow moving
pain when (Billroth brodykinins from 6/10 stics, patient • Ambulate with
moving or II) to at least location, explore minimal
turning on
↓ 4 and intensity exacerbat assistance
bed. Stimulation below and ing • ↓ anxiety
of nerve • Demonstr radiation emotional • (-) grimacing
P= movement, endings ate at or • (-) irritability
coughing, sneezing ↓ least 3 • Encourag environm • (-) profuse
Pain nursing ed & ental sweating
Q= stabbing
interventi demonstr factors • (↓) weakness
R= radiates to ons to ate deep that may
sides of the abdomen relieve breathing affect LONG TERM GOAL:
pain. exercise pain Goal met as evidence
S= rated pain 6/10, • Ambulate • May by; patient was able to
10 as severe pain and without • Encourag relieve verbalized pain relief
0 as none assistance ed use of pain and from 4 to 1 in scale of
• ↓ anxiety pillow to 1-10
T= sudden, • (-) over the enhance
insidious grimacing incision to circulation • V/S
• (-) support T-37.4
• Presence irritability wound P-72bpm
of incision • (-) profuse specially • Relieve R-14cpm
• Anxious sweating when muscle BP-120/80mmHg
• Restless • (-) moving pain
• (+) weakness (SPLINTIN tension
grimacing G) and
• With LONG TERM spasm, to
profuse GOAL: • Performe avoid
sweating Throughout the d muscle
• Weak, pale hospitalization, divertiona stretching
• Hesitant to the patient will be l activities
move and able to:
ambulate • Verbalized • Positioned
• With pain relief to her
guarding from 6 to 1. determine • To divert
behavior d comfort the
on incision attention
site • Encourag from pain
• V/S ed to eat
T-38.5 foods rich • To
P-120bpm in Vit. C enhance
R-33cpm comfort
BP-110/80 and
COLLABORATIVE control
: pain
Administered
medication as • To
prescribed: enhance
• Nalbup wound
hine 1 heating
amp
PRN for
breakth
rough
pain
• Tramad
ol
drip(5 • Use to
amp reduced
+1/2 L pain or
D5W control
*KVO)