Objective Data:
> V/S: BP: mmHg, RR: 21cpm, PR: 65 bpm , Temperature: 36.6 ‘C
> conscious and coherent
> grimacing noted when moving
> guarding behavior noted
> slow careful movements noted
> needs maximum assistance in doing ADLs
Nursing Diagnosis:
Acute pain related to ongoing disease process
GOAL
Long Term Objectives: Within 2 days of nursing intervention, the patient will be able to:
- to perform ADLs with decreased non-verbal and verbal cues of pain as manifested by pain scale of 2/10, no grimacing and guarding behavior noted
Short Term Objectives: Within 8 hours of nursing interventions, patient will be able to verbalize relief of pain as manifested by:
- Pains scale of 5/10 from 3/10
- Less grimacing when moving
- Decreased incidence of needed assistance
- reports pain is within tolerable levels like experiences pain when pressure is applied to the affected area