Villamin, Princess Marjorie A.

Section II-I NURSING CARE PLAN Assessment Nursing Diagnosis Analysis Goal Nursing Intervention
Perform a comprehensive assessment of reported pain including its location and severity Subjective: Client verbalized Medyo masakit pa ang puson ko Pain scale: 2/10 Objective: Client exhibits slight facial grimace, and positions herself to avoid pain Acute pain related to interruption in skin and tissue layers as manifested by verbal complaints, a pain scale of 2/10, facial grimace, and a guarding position Pain is a subjective incident usally manifested by verbal reports of the client. It is important for pain to be relieved to promote clients health and wellbeing Short term: After 2-3 hours of nursing interventions, Clients pain score will decrease from 2/ 10 to 0/10 Longterm: After 8 hours of nursing interventions, client will have no further complaints of pain

Rationale
It allows distinguishing appropriate nursing interventions needed and serves as a baseline data in evaluating interventions It allows performance of actions with the cooperation of the patient A quiet environment is conducive to decrease anxiety of the client Provides pain relief

Evaluation

Establish a therapeutic relationship Provide a quiet environment; decrease stimuli Encourage diversional activities such as socialization and watching TV Instruct client in position changes Assess clients response to pain relief measures

After 2 hours of nursing interventions, pain was relieved and there were no further complaints verbalized by the client as evidenced by absence of facial grimace, and a pain scale of 0/10

To enable the client to find a comfortable position It determines effectiveness of pain relief measure and to modify interventions