Time and Cues Need Nursing Diagnosis Objectives of care Nursing Intervention Implementation Evaluation

date

Subjective cues: That within my 8 hours 1.) Provide quiet August 23, 2019
A “Nagasakit akong C Acute Pain related span of nursing care, my environment and reduce At 3:00PM
U likod permi O to musculoskeletal patient will be able to: stressful stimuli. e.g. limit 2
G Maam” as G discomfort or reduce noise, bright 8 GOAL MET!
U verbalized by the N secondary to a.) Demonstrate light, and constant 1
S patient I prolonged use of interruptions. 3 After my 8 hours span
T T supine/lying relaxation ® Comfort and quiet atmosphere 4 of nursing care, my
I position skills and promote a relaxed feeling and 6 patient was able to:
23, V diversional permit the client to focus on the 7
E activities relaxation technique rather than 9 a.) Site and
2 Rationale: Wrong b.) Encourage external distraction 5 performed
0 P lying position or verbal report relaxation
1 E non-ergonomic during and 2.) Perform a comprehensive techniques like
9 Objective cues: R hospital beds can after the assessment of pain to deep
C trigger pain. It is nursing include location, Pain is a breathing
At 7:00  Facial E because the interventions subjective experience exercise dim
AM grimace P backbone, tendon c.) Reduce and must be described by environment
noted T tissue and muscle concern of the characteristics, onset, b.) Verbalized
 With U lies on a single associated duration, frequency, concerns
Pain A position for a long pain quality, intensity or client regarding the
scale of L time. It can cause d.) Dangle legs in order to plan effective concept of
7/10 fatigue in the and change treatment. severity, and pain and how
 Vital P muscle tissue, positions like precipitating factors of to avoid it
signs as A especially the back turning to pain. c.) Verbalized
follows: T of the lumbar sides every ® Pain is a subjective alleviation of
T muscles. hour experience and must be pain with pain
E described by the client in order to scale of 3/10
R plan effective treatment. d.) Practiced
N 3.) Teach the use of turning
nonpharmacologic schedule from
 techniques (e.g., time to time
relaxation,guided and sit on
imagery, music therapy, upright
distraction, and massage) position with
before,after, and if dangling legs
possible during painful
activities; before pain
occurs or increases; and
along with other pain
relief measures.
®The use of noninvasive pain
relief measures can increase the
release of endorphins and
enhance the therapeutic effects
of pain relief medications.
4.) Evaluate the
effectiveness of the pain
control measures used
through ongoing
assessment of pain
experience.
® Research shows that the most
common reason for unrelieved
pain is failure to routinely assess
pain and pain relief. Many clients
silently tolerate pain if not
specifically asked about it.
5.) Provide optimal pain
relief as prescribed.
®Each client has a right to expect
maximum pain relief. Optimal
pain relief using analgesics
includes determining the
preferred route, drug, dosage,
and frequency for each
individual. Medications
ordered on a prn basis should be
offered to the client at
the interval when the next dose is
available.
6.) Monitor vital signs every
4 hours or as needed
® Changes in vital signs may
mean onset of pain.
7.) Reduce or eliminate
factors that precipitate or
increase the pain
experience (e.g., fear,
fatigue, monotony, and
lack of knowledge).
® Personal factors can influence
pain and pain tolerance. Factors
that may be precipitating or
augmenting pain should be
reduced or eliminated to enhance
the overall pain management
program.
8.) Evaluate the patient’s
response to pain and
management strategies.
®Inconsistencies between
behavior or appearance and what
the patient says about pain relief
(or lack of it) may be more a
reflection of other methods the
patient is using to cope with the
pain rather than pain relief itself.
9.) Sit as regularly as
possible with proper
support.
® The lumbar area has the
backbone that supports most of
the body weight of a human
body, this structure makes all the
movements of the body possible
and provides flexibility to the
body. Regular movement can
avoid muscle spasm or lower
back pain.