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GOALS AND

ASSESSMENT NURSING INTERVENTIONS RATIONALE EVALUATION


OBJECTIVES
Masakit yung sugat ko. LONG TERM: DX:
Hindi ako masyadong Assess pain characteristics: Assessment of pain experience is the first
makagalaw. - Quality (e.g., burning, sharp, step in planning pain management
Pain rated as 7/10 SHORT TERM: shooting) strategies. The most reliable source of
and characterized as - Severity (scale of 0 or no pain to information about the pain is the patient.
sharp, localized at After 30 minutes of 10 or most severe pain
the operative site, nursing intervention, - Location (anatomical
sudden, the patient will be able description)
intermittent, to: - Onset (gradual or sudden)
aggravated by - Duration (how long; intermittent
movement and Report pain is or continuous)
relieved by pain controlled or - Precipitating or relieving factors
medications. relieved, with a
Grimace noted upon pain scale of Observe nonverbal cues/pain Observations may be not congruent with
moving. 2/10 from 7/10. behaviours and other objectives verbal reports.
Guarding behaviour Demonstrate defining characteristics, as noted,
noted. use of especially in persons, who can
With limited relaxation skills communicate.
answers to and diversional
questions. activity such as Foresee the need for pain relief. Preventing the pain is one thing that a
Sweating noted on deep breathing patient experiencing it can consider.
the forehead and at exercises. Early intervention may decrease the
the back. Vital signs total amount of analgesic required.
Vital signs as within normal
follows: range. Acknowledge reports of pain Ones perception of time may become
BP = 140/80 Rest or sleep. immediately. distorted during painful experiences.
RR = 24cpm Pain can be aggravated with anxiety and
PR = 98bpm fear especially when pain is delayed. An
T = 37.2 immediate response to reports of pain
may decrease anxiety in the patient.
Acute Pain related to TX:
inflammatory Provide rest periods to promote Ones experiences of pain may become
process secondary relief, sleep, and relaxation. exaggerated as a result of exhaustion.
to post-operative Pain may result in fatigue, which may
surgical incision. result in exaggerated pain. A peaceful
and quiet environment may facilitate
rest.
Provide analgesics as ordered,
evaluating the effectiveness and Effectiveness of pain medications must
inspecting for any signs and be evaluated individually because it is
symptoms of adverse effects. absorbed and metabolized differently by
patients. Analgesics may cause mild to
severe side effects.
Report to the physician when
interventions are unsuccessful and Patients who demand pain medications
ineffective. at more frequent intervals than
prescribed may actually require higher
doses or more potent analgesics.

EDX:
Encourage verbalization of feelings
about the pain. Only the client can judge the level and
distress of pain; pain management
should be a team approach that includes
the client. Very few people lie about pain.
Encourage and assist client to do
deep breathing exercises. Deep breathing for relaxation is easy to
learn and contributes to pain relief
and/or reduction by reducing muscle
tension.