NCP Acute Pain Va

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Date Nursing Diagnosis

& Assessment Needs Objective Interventions Evaluation


Time
Jan. Subjective: C Acute pain related to After 8 hours of 1. Perform a comprehensive assessment. GOAL MET
22, “Usahay O vehicular accident nursing Assess location, characteristics, onset,
2019 makabati sya G interventions, duration, frequency, quality and After 8 hours of
ug kasakit N R: Vehicular accident the patient will severity of pain. nursing
7:00 basta I injury inflicts wounds be able to: R: Assessment is the first step in interventions,
am – matandog T which are either caused managing pain. It helps ensure that the the patient was
3:00 iyang mga I by skin damage, nerve - report patient receives effective pain relief. able to:
pm samad, V damage, blood vessel satisfactory pain
mahalata man E injury, infection or control on a rate 2. Accept patient’s description of pain. - - report
kay maglain ischaemia which results of 6/10 R: Pain is highly subjective satisfactory pain
ang nawong” - to pain. - use control on a rate
as verbalized pharmacological 3. Obtain vital signs. of 6/10
by the wife of P Source: K Baheti, D., and non R: Vital signs are usually affected when - use
the patient. E Bakshi, S. and Gupta, pharmacological pain is present. pharmacological
R S. (2016). pain relief and non
Objective: C Interventional Pain strategies 4. Anticipate the need for pain relief. pharmacological
E Management: A R: Early and timely intervention is key to pain relief
- reports of P Practical Approach. JP effective pain management. It can even strategies
pain T Medical Ltd, p.675. reduce the total amount of analgesia
through U required.
writing A
- facial mask L 5. Provide a calm and comfortable
of pain environment.
- pain scale P R: Calm and comfortable environment
of 8/10 A induces sense of relief to patient.
T
- Vital Signs T
recorded at: E
Temp: 36.5 R
BP: 120/80 N 6. Get rid of additional stressors or
RR: 22 sources of discomfort whenever
PR: 80 possible.
R: Patients may experience an
exaggeration in pain or a decreased ability
to tolerate painful stimuli if
environmental, intrapersonal, or
intrapsychic factors are further stressing
them.

7. Provide rest periods to promote relief,


sleep, and relaxation.
R: Pain results to fatigue which leads to
exaggerated pain.

8. Teach techniques of
nonpharmacological pain relief methods
(relaxation exercises, breathing exercises,
music therapy).
R: Works by increasing the release of
endorphins, boosting the therapeutic
effects of pain relief medications.

9. Administer medications as prescribed.


R: Paracetamol, also known as
acetaminophen and APAP, is a medicine
used to treat pain and fever. It is typically
used for mild to moderate pain relief.

10. Document patient’s response to pain


management.
R: It helps the entire healthcare team
evaluate their pain management strategy.

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