Patient’s name:

room & bed #:

Diagnosis:
physician:

Chief complaint:

DA CUES NURSING NEE OBJECTIVES OF NURSING INTERVENTION EVALUATION

TE DIAGNOSIS D CARE
 S Acute pain C At the end of my 1. Note location of surgical July 7, 2010
J >The patient related to O 8 hours span of incision. @
U verbalized, tissue injury G care, my patient ®this can influence the 11 pm
L “Agay!sakit. secondary to N will be able to: amount of postoperative “GOAL
Y Sakit gihapon exploratory I a. report pain pain experienced. PARTIALLY MET”
akong laparotomy T is 2. Note client’s locus of
7, tinahian.” I controlled; control. At the end of my
>”Ayaw lang ®Pain is an V b. follow ®individuals with external 8 hours span of
2 hilabti sa akong unpleasant E prescribed locus of control may take care, my patient
0 tiyan banda kay and highly - pharmacolo little or no responsibility was:
1 sakit.” personal P gical for pain management. a. unable to
0 experience E regimen; 3. Accept the client’s report
O that may be R and description of pain. control of
@ >vertical imperceptibl C c. verbalize ®pain is a subjective pain;
incision below e to others, E nonpharmac experience and cannot be b. able to
3P the sternum while P o-logic felt by others. take all
M bypassing the consuming T methods 4. Observe non-verbal due oral
umbilicus up to all parts of I that provide cues/pain behaviors. medication
2 inches below the person’s O relief. ®observation may/may s for pain
the umbilicus life. It is N not be congruent with or
>guarding of usually a verbal reports or may be analgesics;
abdominal area response to P only indicator present and,
>changes actual tissue A when client is unable to c. able to
position slowly damage, so T verbalize. verbalize,
to avoid pain there may T 5. Monitor skin “dapat
>irritable not be E color/temperature and mag deep
>changes in abnormal R vital signs. breathing
vital sign laboratory or N ®these are usually para dili
especially the radiographic altered in acute pain. mulala ang
cardiac rate and reports 6. Determine client’s sakit sa
pulse rate despite real acceptable level of akong
>sighing pain. pain/pain control levels. samd.”
>grimaced face ®it varies with the
>analgesic individual and situation.
medications 7. Note when pain occurs.
®to medicate
 prophylactically, as
appropriate.
8. Provide comfort
measures, and quiet
environment.
®to promote
nonpharmacological pain
management.
9. Instruct in/encourage use
of relaxation techniques
such as focused deep
breathing.
®to distract attention and
reduce tension.
10. Administer
analgesics as ordered.
®to maintain acceptable
level of pain. Notify
physician if regimen
inadequate to meet pain
control goal.
11. Encourage adequate
rest periods.
®to prevent fatigue.