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MSPM
ASSESSMENT
DIAGNOSIS
SUBJECTIVE: Acute pain related to Masakit ang tahi ko as tissue injury secondary verbalized by the client. to surgical incision; Caesarian Section PS: 8/10 OBJECTIVE: - Facial grimace - Guarding behavior - Restlessness Vital signs taken: T: 37 P: 83 R: 19 BP: 110/80
PLANNING
INTERVENTION
Dependent: Administer Tramadol, After 1 hour of nursing intervention the client will as ordered. be able to report pain is relieved. Independent: Provide calm quiet environment
RATIONALE
EVALUATION
STG:
LTG:
After 24 hours of nursing intervention the client will be able to demonstrate ways on how to manage pain.
Instruct deep breathing exercises
Encourage diversional activities (e.g. listening to music)
Encourage adequate rest periods.
Pharmacologic treatment to relieved pain.
To avoid stress in patient that may worsen pain.
Non-pharamacologic measures that provides relief of pain.
Increases release of endorphins and enhance the therapeutic effects of pain management program.
Promotes a relaxed feeling to the patient.
After 1 hour of nursing intervention the client reported pain is controlled with pain scale of 3/10.
After 24 hours of continuous nursing intervention the client was able to manage pain.
