Date/ Nee Nursing Objective of

Cues Nursing Interventions Evaluation

Time d Diagnosis Care

Subjective: C Chronic pain At the end of 1. Monitor Vital Signs April 17, 2010 @
® to have a baseline data and 10pm
A O related to dysuria our 8 hours
vital signs usually alter in acute Goal met
U “Gasakitman G and polyuria span of care, pain
G ang akoang N the patient will After 8 hours of
2. Establish rapport
U pagkatao kung I ® Chronic pain is be able to report ® to gain trust and cooperation our care, patient
an unpleasant
S mangihi ko. T relieved to a was able to rate
sensory and 3. Note location of pain, onset
T Gamay lang I emotional satisfactory and duration, precipitating and his pain scale
experience aggravating factors.
pud akoang V level 1-4 as from 4 to 3.
arising from Rationale: It is important that the
2 maihi.” As E actual or potential mild. underlying cause of pain is
tissue damage or managed first to relieve pain
9 verbalized by
described in experienced.
patient P terms of such
damage. 4.Assess pain in a patient using
2 -Pain scale of E
(International a self-report 0 – 10 numerical
0 4 out of 10 as R Association for pain rating scale.
the Study of Pain) ®Single-item ratings of pain
0 1-4 mild; 5-7 C
intensity are valid and reliable as
9 moderate; 8- E measures of pain intensity.
10 severe. P
5. Perform pain assessment
@ T each time pain occurs.
12 Objective: U ®to rule out worsening of
underlying condition
MN -Grimaced A
face noted L 6. Allow the patient to verbalize
feelings
-eyes lack
® because pain is a subjective
luster
P experience and cannot be felt by
-beaten look
others and for further
-reduced A
assessment
interaction
T
with people
7. Provide comfort measures
T
such as stretching the linen
E ® to provide
nonpharmacological pain
R
management
N
8. Encourage diversional
activities such as engaging
conversation with SO
® to divert attention away from
pain

9. Encourage adequate rest

periods
® to prevent fatigue and
promote rest

10. Discuss ways to lessen pain,

including minimizing movement
and relaxation skills
® to help patient lessen the pain
felt