Date/ Nursing Objectives of

Cues Need Nursing Interventions Evaluation

Time Diagnosis Care
C Acute Pain That within the 2 1. Respond immediately to complaint of pain. February 18, 2010
Subjective cue: O related to hour span of care, ® Prompt responses to complaints may result @
“Sakit dira dapit.. G irritation from the patient will in decreased anxiety of the patient. 9am
(pointing on her left N stone in the experience relief Demonstrated concern for the patient’s
side I urinary tract. of pain evidenced welfare and comfort fosters the development GOAL MET!
abdomen),mas T by: of a trusting relationship.
sakit sya kung I ® Calculi form After 2 hour span
gnapalpate gud.” V primarily in the a. complain of 2. Observe or monitor Vital Signs, of care, the patient
As verbalized by E kidney pain will reduce, restlessness and guarding behavior. experienced relief
the patient (nephrolithiasi with the pain scale ® Some people deny the experience of pain pain as evidenced
A s), but they of 4-5 out of 10. when it is present. Attention to associated by:
Objectives cues: N can form in or signs may help the nurse in evaluating pain.
• Pain Scale of 6 D migrate to the b. has a normal a.) Pain scale of 4
0-1 No pain lower urinary range vital signs 3. Determine specifics of pain, e.g., location, b.) Vital Signs are
2-3 Mild pain P system. The BP=90/70-140/90 characteristics, intensity (0–10 scale), in normal
4-5 Discomforting - E most mmHg onset/duration. range.
moderate pain R characteristic T= 35.5-36.5 C ® Facilitates diagnosis of problem and Temp= 36.2 C
6-7 Distressing - C manifestation RR= 16-20cpm initiation of appropriate therapy. Helpful in PR=74
severe pain E of renal or PR=80-90bpm evaluating effectiveness of therapy. CR=79
8-9 Intense - very P ureteral calculi CR=80-90bpm RR=20
severe pain T is a sharp, 4. Note non-verbal cues. BP=120/80 mmHg
10 Unbearable U severe pain of c. verbalize relief ® To determine whether the patient is really c.) Patient
pain A sudden onset of pain. experiencing pain without even asking. verbalized that
• Grimaced Face L caused by “Naa lng

• Expressive movement of 5. Provide rest periods to facilitate comfort, gihapon ang

behaviour P calculus and sleep, and relaxation. sakit pro

(sighing) A consequent ® The patient’s experiences of pain may compaired sa

• C/C: Left hemi- T irritation. become exaggerated as a result of fatigue. A first day ko dito
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abdominal pain T Depending on quiet environment is a measure geared ngbawas-
E the site of the toward facilitating rest. bawasan maski
• PE:
R stone, this papano ang
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