Assessment Explanation of the Expected Goal Nursing Interventions Rationale Criteria for evaluation

problem
June 23, 2008 The patient is post GOAL: Dx: Objectives fully met, if:
menopausal, and
After 2 days of ➢ Assess pain ➢ Assessing the pain intensity of the a. Patient will not
being in the post
nursing using the individual provides a clear demonstrate
S>”Nasakit tay tiyan ko menopausal stage
intervention the PQRST method. representation of the subjective grimaces.
sobra, sobra ti sakit na, means you have
patient will perception of the pain and b. Patient verbalizes
pati idtoy likod ko lesser bodily
demonstrate provides a background for decreased pain.
nakasaksakit.” secretions
activities that choosing appropriate c. Patient is
because of the
decrease pain interventions to relieve the pain. practicing
depletion of
perception like relaxation
O> V/S: estrogen in the
distractions and ➢ This objective cues are non- techniques
body, this could
BP: DBE verbal cues that provides
possibly be the
information to validate the
PR: cause of the
➢ Monitor objective subjective data the patient has Objectives partially met,
ineffective
T: OBJECTIVES: cues of patient. provided. By looking and if:
mucosal barrier of
comparing at the data with the
RR: the bladder and After 8 hours of a. Patient will
physiology of pain findings will be
possibly the nursing demonstrate an
>Facial grimaces are more accurate thereby providing
vagina making intervention, on and off pain.
noted more appropriate interventions.
bacteria enter the b. Patient verbalizes
a. The
>Frequent sighing noted. urethra causing pain every after 4
patient will
further hours.
>Patient holds her demonstr ➢ Assessing the patient’s capacity
inflammation to c. Patient cannot
abdomen as she ate less to understand helps disseminate
the deranged learn relaxation
grimaces grimaces information most especially if it is
bladder. techniques
b. The planned to give supplemental
>Patient puts belt around Characteristic accurately as
patient will readings.
abdomen to lessen pain symptoms include taught
be able to
a sensation of
verbalize ➢ Assessing the patient’s
bladder fullness, ➢ Assess patient’s
decreased willingness to learn means
A: Acute Pain related to frequency, intellectual Objectives not met, if:
pain assessing patient’s level of
inflammation of bladder’s urgency, nocturia, capacity.
c. The cooperation—the more the patient a. Patient still
interstitial layers scanty urine per
patient will cooperates the more effective is grimaces.
voiding, and
be able to the intervention. b. Patient continues
suprapelvic and
urethral pain. practice to verbalize
relaxation ➢ Providing rest periods helps increasing pain
technique decrease the pain perception of c. Patient refuses to
s like ➢ Assess patient’s the patient. An environment learn relaxation
imagery willingness to crowded by several people and techniques
learn to disturbed by interventions
decrease pain . disturbs the rest period of the
patient.

➢ Eliminating other sources of pain

will make the patient feel secured
Tx:
and comfortable.
➢ Provide rest
periods for
patient to
enhance
relaxation

➢ DBE helps patient to relax from

the stress that is experienced

➢ Eliminate
additional known
sources of pain
that makes
patient
➢ Offering distractions to patient
comfortable
helps divert the perception of pain
to other things rather than pain
itself.
➢ Provide patient
time to perform
DBE when
experiencing too
 much pain

➢ Offer patient
relaxation ➢ Arcoxia is a drug that contains
techniques that cyclooxygenase-2 specific
can be done inhibitor, cyclooxygenase-2 are
easily like thought to specifically inhibit
imagery or if inflammation and control pain.
possible music
therapy.
➢ Teaching the patient the proper
➢ Administer way of doing DBE helps increase
Arcoxia 120 mg the participation of the patient in
as prescribed performing a way to relax herself,

➢ Instructing patient while still in her

fully awake and normal state will
EDx: orient the patient to any
unnecessary sensation at hand
➢ Teach patient the
like that of a surprise attack of the
proper way to
pain; this instruction will help the
perform DBE
patient to immediately act out
certain relaxation techniques
when it is hardly possible for a
teaching
➢ Instruct patient to
continue
➢ This intervention will inform the
relaxation
student nurse about the severity
techniques when
of the patient’s condition at that
pain is felt
certain moment so that the
student nurse could report it
immediately to a higher authority
of the health care team
 ➢ Instruct to patient
to report
immediately if
pain is no longer
tolerated

References:
Understanding Pathophysiology by McCance
Nurses’ Pocket Guide by Doenges
Nursing Care Plans 7th Edition by Doenges
PPD 13th annual edition
Mosby’s Drug Guide