Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation

 SUBJECTIVE Acute pain related to post- Goal:  Obtain client’s /  Obtaining the After the nursing
The client verbalized op surgical incision (C/S) After the nursing significant other’s (SO) clients assessment of intervention, the client
“Ang sakit ng tahi ko pag with hypertension intervention, the client will assessment of pain to pain helps the was able to:
naglalakad tapos medyo be able to report a decrease include location, nurse/physician to fully  Verbalize
nahihilo ako kahit of pain from 7 to 4 and characteristics, onset, understand the client’s nonpharmacological
nakaupo” below duration, frequency, symptoms of pain methods that provide
quality and intensity. relief
Pain Scale: 7/10 Objectives: Identify the  Perform pain
After the nursing aggravating and assessments in order  Demonstrate use of
 OBJECTIVE intervention, the client will precipitating factors to demonstrate relaxation skills and
be able to: improvement in status diversional activities,
Guarding behavior;  Perform pain or to determine and as indicated.
protective behavior;  Report relief and assessment each time identify worsening of
positioning to ease pain control from pain the pain occurs, record an underlying  Verbalize sense of
and investigate condition or control response to
Facial expression of pain  Perform pain changes from previous developing acute situation and
Diaphoresis (change in management assessments and complications positive outlook for the
blood pressure) evaluate results of pain future.
 Demonstrate different interventions.  To know client’s own
relaxation techniques perception for pain
Vital Signs  Note client’s attitude or medications and to
BP: 160/90 to decrease pain
opinion towards pain inform the client for
Temp: 37.1℃ and use of pain possible options
 Follow prescribed
PR: 82 medications
pharmacological
RR: 20  To maintain an
regimen
 Administer “acceptable” level of
medications such as pain for the client.
analgesics (pain
killers) as indicated, to  To know if the dosage
needs to be increased
 maximum dosage as or decreased, and if it
needed. needs to be switched
 Evaluate and document from injection to oral
the client’s response to route as it can help in
analgesia and assist in self-management of
altering or pain.
transitioning drug
regimen

Nursing Care Plan Name: Section: Date: