Need/Nursing Objective Scientific Nursing

Rationale Evaluation
Diagnosis/Cues Analysis Intervention
Need: After 6-8hrs of Acute pain is an >Monitor vital >Alterations from
Physiologic need nursing unpleasant sensory and signs normal maybe
intervention the emotional experience signs of infection
Acute Pain related to patient will be arising from actual or
spasm at upper able to: potential tissue damage >Perform an -Indicates need
extremities or described in terms of assessment of for/ effectiveness
>Report pain is such damage pain to include of interventions
S-> relieved/control (international association location, and may signal
“Magsakit ako led, with the for the study of pain); characteristics , development/
bukton” as verbalized pain scale of sudden or slow onset of onset/ duration, resolution of
by the patient, with the 3/10 from 9/10 any intensity from mild frequency, complications.
pain scale of 9/10. to severe with an quality, severity,
> Verbalize anticipated or predictable grimacing ( 0 –
O-> understanding end and a duration of 10 scale)
*Patient seen sitting of condition. less than 6 months.
on bed >Provide -To promote non
>verbalize Source; Contemporary comfort -pharmacological
*patient shows method that Medical Surgical measures, quiet pain management
weakness and provide relief Nursing, Daniels R., environment and
evidence of pain NosekL.,Nicoll., pp.992. calm activities
>demonstrate
*guarding behavior use of >Encourage To distract
(restless) relaxation skills diversional attention and
and diversional activities and reduce tension
*distraction behavior activities relaxation
techniques such
*BP = 130/90mmHg as focused
breathing and
*Self-focusing or imaging
narrowed focus
>Administer -To maintain
analgesics, as “acceptable” level
indicated, to of pain
maximum
dosage, as
needed