ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Independent
Subjective Data: Acute Pain GOALS:  Monitor vital  For baseline After 30 minutes
“Tyan ko po masakit” as and After 30 minutes of sign data and for of nursing
verbalized Discomfort nursing intervention the further interventions, the
related to patient will be able comparison client was able to:
Dengue decrease/ alleviate the
pain  Observation of  Observation a. Report that her
the patient's of the patient's pain was relieved
 Verbalize reports level of pain level of pain
that provide relief. (scale, (scale, b. Demonstrate use
b. Demonstrate use frequency, frequency, of relaxation skills
of relaxation skills duration). duration). and diversional
and diversional activities.
activities as  Observation of  Observation
Objective Data: indicated for the patient's of the patient's
 Respiratory Rate of individual level of pain level of pain
12 cycles per situation. (scale, (scale,
minute frequency, frequency,
 Cardiac Rate: 97 duration). duration).
beats per minute
 O2Saturation: 98%  Teach the  Refocused
 (+)guarding patient attention
behavior relaxation improve the
techniques. ability to cope
with pain.
Dependent
 Administration  Provide
of analgesics as pain relief.
ordered