ASSESSMENT DIAGNOSIS GOAL INTERVENTION EVALUATION

Subjective: Acute pain related to Plan: Establish rapport.

biological factors such After 8 hours of nursing
“Hirap ako umihi…” as After 8 hours of nursing Monitor and record V/S. interventions, the
as trauma or activity of
verbalized by the interventions, the patient’s pain will be
disease process Establish good
patient patient’s pain will be relieved or controlled.
relationship, listening
relieved or controlled.
Objective:· carefully and attending
to client’s verbal and
Facial grimace.
non-verbal expressions.
Restlessness.
Independent:
V/S taken as follows:
· Assess pain, noting
T: 37.3
location, intensity (scale
P: 82
of 0 – 10)
R: 19
BP: 120/90 Encourage increase of
fluid intake.
Investigate report of
bladder fullness.·
Observe for changes in
mental status, behavior
or level of
consciousness.