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Problems And Cues Diagnosis Planning Intervention Rationale Evaluation

Subjective: Acute Pain r/t After 3 hours of Independent: After 3 hours of

“ Nakirot ung disruption of nursing intervention - Assess location, - To assess the nursing intervention
sugat ko” as skin, tissue and the patient pain will characteristic, etiology or the patient pain
verbalized by the muscle integrity alleviate as onset, duration, precipitating factor alleviated as
patient. secondary to evidence by: frequency , quality evidence by:
Surgical patient’s and severity of pain patient’s
Objective: incision as evidence verbalization of - Note location of - As this can verbalization of pain
>with pain scale of by: pain scale of 7/10 surgical incision influence the scale of 7/10 down
7/10 patient’s down to 0 amount of post-op to 0
>with facial verbalization of - (-)facial experience - (-)facial
grimaces pain grimace - Perform - To rule out grimace
>cool clammy skin with a pain scale of - (-) cool assessment each worsening of - (-) cool
>T: 36.6 °C 7/10, facial grimace, clammy skin time underlying clammy skin
PR: 92 bpm pain occurs, note condition or
RR: 22 cpm and cool clammy and investigate development of
BP: 120/90 mmHg skin changes from complication
previous reports
- Monitor V/S - V/S are usually
altered in
acute pain
- Provide quiet - To prevent fatigue
environment and
encourage adequate
rest period

- Encourage use of -To encourage sense

relaxation of
technique and control and improve
control or
- Provide additional alleviate pain
measures such as
back rub,
changing patient’s
position, change
linen as necessary

- Administer
analgesic as ordered - To relieve general
- Instruct patient’s
significant others
- To maintain
to help patient
divert pain into
level of pain