Patient’s Name: Banilad, Arvin

Age/ Sex: 14/M

Diagnosis: MHI sec. VA

Institution: SPMC

Diagnosis/Cue Need

Desired outcomes Nursing Intervention Rationale Evaluation statement

Acute Pain on Right Shoulder r/t physical trauma as manifested by guarding behavior and facial grimace

SUBJECTIVE CUES:

verbalized “Sakit kaayo akong abaga dili nako gusto ilihok.”

OBJECTIVE CUES:

Rated pain as 6 out of 10

Facial grimace

Gurading behavior (+)

T: 36.6

PHYSIOLOGIC

After 4 hours of nursing interventions, the patient will be able to;

General: Become relieved of

signs and symptoms of pain experienced as evidenced by:

Specific: Verbalize pain is

relieved (rate pain from 0-4 out of 10)

Demonstrate use of diversional activities

INDEPENDENT

1. assess contributing factors to pain (noise, wrong positioning, environment)

2. review medication regimen

3. ask client to rate pain on 0-10 scale (rated as 9 out of 10)

4. provide comfort measures such as repositioning the client in a comfortable position and providing a hot or cold compress

5. provide calm and quiet environment (adjust

1. to determine underlying cause of pain and treat accordingly.

2. certain drugs may cause fatigue and drowsiness.

3. to assist in evaluating impact of pain on client’s life.

4. to allow nonpharmocological pain relief and promote good circulation to the brain and decrease vasoconstriction

Goal unmet. Patient verbalized “Sakit gihapon akong abaga, di gihapon nako ilihok.”

Goal met. Patient was able to relax by utilizing bed rest and deep breathing.

P: 72 bpmR: 21 cpmBP: 110/70 mmHg

BACKGROUND KNOWLEDGE:

Acute pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severed with an anticipated or predictable end and a duration of less than 6 months.

SOURCE:

Nurse’s Pocket Guide: Diagnoses, prioritized interventions and rationales 11th Ediction by Marilynn Doenges

Brunner and Suddarth’s Textbook of Medical-Surgical Nursing 11th

such as relaxing and/or sleeping

Rest and feel rested after adequate rest interval

Utilize non-pharmacological methods of pain relief ( deep breathing, guided imagery, etc)

Be able to perform ADLs as tolerated

lights, temperature and eliminate offensive odors which may contribute to headache)

6. instructe in relaxation techniques (deep breathing, imagery)

7. encrourage adequate rest periods

8. assist in self-care activities as tolerated

9. provide peaceful \and adequate resting environment (dim lights, adjust temperature, wrinkle-free bed, quiet surroundings)

COLLABORATIVE:

1. administer medications as ordered by physician (analgesics, etc)

5. to decrease environmental factors which contribute to migraine and promote rest.

6. to distract attention from pain and decrease tension

7. to conserve energy of the patient and prevent fatigue

8. To promote client independence as much as possible and acquire sense of function

9. to enhance quality sleep and promote rest which harnesses energy for future use.

Goal met. Patient was able to sleep for 4 hours straight and felt rested afterwards.

Goal met. Client was able to use deep breathing and reported pain relief afterwards.

Goal met. Client was able to perform ADLs with minimal assistance from watchers (feeding, self-care, etc)

Edition by Suzanne C. Smeltzer

2. encourage watchers to assist patient during diversional activities (minimize noise, allow client to verbalize feelings and promote rest and sleep)

1. medications will provide synergistic effect with nonphramacologic interventions for pain relief and promote better circulation by aiding in vasodilation for better blood flow to the brain and altering prostaglandin synthesis to decrease pain

2. the significant others know the client more and will be able to aid in diverting client’s attention from pain.