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Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: Acute Pain related to After 6 8 hours of Independent: After 8 hours of nursing
Tissue Trauma nursing interventions, intervention:
Medyo sakit pa jud ang secondary to Normal measures to alleviate Assess pain Indicates need for
akong kinatawo maam Spontaneous Vaginal pain will be reports, noting effectiveness of Patient pain was
as patient verbalized. Delivery implemented. location, pain interventions and reduced to pain
scale, frequency may signal scale of 1.
Objective: Patient pain will and onset. Note development of Patient showed
be reduced from a nonverbal cues. complications. signs of comfort
(+) lumbar pain, pain scale of 6 to Encourage patient Efficacy of and alleviation of
pain scale = 6. 1 0. to report pain as comfort measures pain.
Exhibits slight Patient will show it develops. and medications Patient was able
facial grimace signs of comfort is improved with to verbalize that
Positions herself and alleviation timely pain is relieved.
to avoid pain. from pain. Encourage intervention. Demonstrated use
Patient at bed rest Patient will verbalization of Can reduce of relaxation
most of the time verbalize that feelings. anxiety and fear techniques and
noted. pain is relieved. and thereby diversion
T 37.2oC Demonstrate use Perform palliative reduce perception activities.
CR 70 bpm of relaxation measures ex. of intensity of
RR 24 cpm techniques and Back massage, pain.
BP 150/80mmhg diversion repositioning. Promotes
activities. relaxation/
Collaborative: decrease muscle
tension.
Administer
analgesics or pain
killers.

Provide relief of
pain and
discomfort.

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