Patient’s Name: Mrs.

MR
Medical Diagnosis: Cellulitis Right Foot, DM II
Nursing Diagnosis: Alteration in comfort: pain r/t tissue trauma as evidenced by 10/10 pain scale
Short-term goal: After rendering nursing care intervention, patient’s pain scale of 10/10 will decrease to 6/10
Long-term goal: After hospitalization, the patient will be knowledgeable about different strategies that can be
effective to relief pain.

Cues Problem Scientific Nursing Intervention Rationale Evaluation

Reason
Subjective: Alteration > Potential >Re-assure patient that >Fear that pain will not >Goal met
“Sobrang in comfort: tissue damage you know pain is real be accepted as real, patient’s pain
sakit ng paa pain or described in and will assist her in increases tension and scale of 10/10
ko, hindi ko terms of such dealing with it. anxiety thus decrease decreased to
na halos damage; pain tolerance. 2/10.
maigalaw” as sudden or slow >Use pain of >Provides baseline for
verbalized by onset of any assessment scale to assessing changes in
the patient. intensity from identify intensity of pain level and
Objective: mild to severe pain. evaluating intervention.
>with dry with an >Data assist in
and intact anticipated >Assess and record evaluating pain and
dressing on predictable end pain and its pain relief and
the right foot and a duration characteristics: identifying multiply
>with pain of less than 6 location, quality, sources and types of
on the right months frequency and duration pain.
foot with a
pain scale of Independent: >May relieve pain and
10/10 >Re-position as enhance circulation
>with non- indicated. >Quiet environment
pitting makes the patient feel
edema on >Provide quiet and relaxed and secured,
the right foot calm and quiet thus decreased
>with facial activities. anxiety.
grimace >In the midst of painful
>Respond immediately experiences a patient’s
to complaint of pain. perception of time may
become distorted.
Prompt responses to
complaints may result
 in decreased anxiety in
>Teach patient the patient.
additional strategies to >Use of these
relieve pain and strategies can be an
discomfort: distraction. effective pain relief.
>Provide additional
comfort measures like >Improves circulation,
back rub. reduces muscle tension
and anxiety associated
>Encourage adequate to pain.
rest periods. >Prevents fatigue and
>Instruct patient and conserves energy for
family about potential healing.
side effects of >Anticipating and
analgesics and their preventing side effects
prevention enable the patient to
management. continue analgesia
without interruption
Dependent: because of side effects.
>Administer balanced
analgesics as >Analgesics are more
prescribed to promote effective if
optimal pain relief. administered early in
pain cycle.
Simultaneous use of
analgesics that work on
portions of the
nociceptive system will
provide greater pain
relief with fewer side
effects.

Reference:
Brunner & Suddarths’s
Textbook of Medical –
 Surgical Nursing 11th
Edition Volume 1

Submitted by:

Sorne, Cleodee R. Group 16 BSN3-4