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Assessment Explanation of the Objectives Interventions Rationale Evaluation

Problem

S: Masakit pa din On April 4, 2017, at STG: Dx Criteria


yung mga sugat ko 10:13 in the evening Within 8 hours of 1. Assessed pain 1. To assess and
while travelling in a nursing status evaluate and evaluate Fully met if:
O: motorcycle on a intervention the effectiveness of Pain rating of<=5/10
>With pain rating scale highway at Urdaneta patient will be the therapeutic Absence of grimacing,
of 7/10 at the wound City, the patient was hit able to: regimen leading to guarding and crying
sites: by another motorcycle Decrease pain the decrease in pain Absence of ear
Right and Left resulting to multiple sensation from sensation discharges
Shoulders injury/abrasions in her 7/10 to =<5/10.
Right and Left elbows body. 2. To understand the Partially met if:
2. Assessed history
Right and Left knee Absence of nature of accident and Pain rating of >5/10
of accident
Right side of the Face Any trauma to the body grimacing, refer to staff if there With grimacing,
cause by an external crying and are any additional guarding and crying
Characterized as sharp, force will cause pain guarding of findings on her case. Absence of ear
burning, non-radiating due to the disruption in wound sites discharges
aggravated by pressure the continuity of the 3. To determine early
3. Assessed level of
and movement and is skin and tissues. Nerve signs of further
consciousness.
relieved by rest. endings are located in LTG: trauma to the brain
the skin where in Within 72 hours leading to loss of Not met if:
>Observed to be trauma will cause it to of nursing consciousness Pain rating of >5/10
Tx
crying, grimacing and be stimulated causing intervention, With grimacing,
guarding wound sites severe pain as patient will be guarding and crying
1. Assisted on wound 1. To provide a clean
perceived by the brain. able to: With bilateral ear
care wound resulting to
>Requires moderate discharges (clear-
assistance when doing Pain is defined as Absence of pain faster wound healing, bloody)
ADLs. unpleasant sensory and preventions of
emotional experience Able to do ADLs infection and
>With swelling of the arising from actual or independently decrease in pain Fully met
2. Clustered nursing sensation
face and hematoma on potential tissue
interventions 2. To allow adequate rest Pain rating of<=5/10
the wound sites damage. No bilateral ear
and sleep leading to Absence of grimacing,
discharge
decrease stimuli to guarding and crying
>Skin is moist, no signs
pain and promotes Absence of ear
of bleeding on the
faster tissue repair discharges
wound sites
3. Listened to
verbalization of 3. To allow patient
>GCS 15
References: concerns express her concerns
>With clear whitish leading to decrease in
discharge on both ears Doenges, M., anxiety and provide
Moorhouse, M. & Murr, emotional support
>With partial/moderate A. (2009) Nurses such as providing
body weakness pocket guide. FA Davis information about the
company. Philadelphia. progress of the case.
4. Administered pain
12th edition. pp. 98-99
medications as 4. To decrease pain
Nursing diagnosis:
ordered: Ketorolac sensation by inhibiting
Acute pain related to
IV and TDL+PCT the COX1 and COX2
tissue trauma
500mg 1 tab enzymes responsible
secondary to motor
vehicular accident for prostaglandin
synthesis resulting in
pain sensation and
inflammation
Edx

1. Encouraged to do
diversional 1. To divert patients
activities such as focus to non-pain
talking with stimulating
relatives and environmental stimuli
listening to music resulting to decrease
in pain sensation
2. Instructed family
members to assist
2. To provide bodily
patient upon
support when moving
moving
and pain sensation
caused by movement
3. Taught on proper and pressure.
deep breathing
3. To allow diversion of
exercise
focus, relaxation of
muscles and
increasing oxygen
supply in the brain
leading to faster
4. Instructed to
recovery.
report severe pain,
or decrease in the
level of 4. To immediately
consciousness. provide ordered PRN
medications (KETO
and PCT) and nursing
interventions leading
5. Advised patient to to decrease sensation
limit alcohol of pain.
intake.
5. To prevent re-
occurrence of motor
vehicular accident
that may lead to more
6. Encouraged to life-threatening
increase fluid injuries.
intake as
tolerated. 6. To replace body fluids
due to bleeding and
prevents cellular and
tissue dehydration
leading to faster
recovery.