NCP- PAIN (CLICK HERE!!!)

Cues	Nursing Diagnosis	Goals and Objectives	Nursing interventions	Rationale	Evaluation
Subjective: - Patient verbalized: “Sumasakit dito ko (referring to abdomen), parang may naninigas sa loob…dati pa to eh, medyo bata bata pa ko.” Objective: -Pain scale of 6 for abdominal pains. - Exhibits facial grimace upon palpation of the abdomen. -Shows signs of  Irritability - Restlessness Vital Signs: BP – 120/80 PR – 87 bpm RR – 32 breaths/min Temp – 37.4	Chronic pain related to abdominal cramps secondary to non-ulcer dyspepsia	Long Term: After 3 days of nursing intervention the patient will be able to experience gradual reduction / relief of pain from a pain scale of 6 to at least 3. Short Term: After series of nursing interventions, the patient will be able to: - Verbalize reduction/ relief of pain in the abdomen. - Feel and palpate abdomen without facial grimace and moaning.        - Recite and demonstrate some non-pharmacologic ways to lessen pain.	Independent: -Provide comfort measures such as use of pillows under extremities and periodic wound cleaning on affected area. - Encourage and assist client to do deep breathing exercises. - Teach client and significant other about the non-pharmacologic ways to lessen the pain. - Instruct client to report any improvement/exacerbation in pain experience. - Encourage verbalization of feelings about the pain. - Physical Examination: Periodic auscultation of the abdomen for bowel sounds Inspection and Palpation for masses and tenderness. Dependent: - Administer medications, particularly analgesics, as prescribed. - Assist with laboratory/diagnostic studies as indicated. (e.g., abdominal X-ray)	To promote relief and wellness. Deep breathing exercises contribute to relief of pain To maximize opportunities for self-control over pain manifestations. Only the client can judge the level and distress of pain; pain management should be a team approach that includes the client. Necessary for management of underlying and possible complications.

Cues	Nursing Diagnosis	Goals and Objectives	Nursing interventions	Rationale	Evaluation
Subjective: - Patient verbalized: “Ang sakit nun (pointing to left lower leg)... kumikirot!” Objective: - Pain scale of 8 for pain felt at the left lower leg. - Exhibits facial grimace and moaning upon movement of  the left lower leg. -Shows signs of  Irritability - Restlessness -Physical immobility Vital Signs: BP – 120/80 PR – 87 bpm RR – 32 breaths/min Temp – 37.4	Acute pain related to immobility / improper positioning	Long Term: After 8 hours of nursing interventions, the patient will be able to experience gradual reduction / relief of pain from a pain scale of 8 to at least 4. Short Term: After series of nursing interventions, the patient will be able to: - Verbalize reduction/ relief of pain. - Move her left lower extremity without facial grimace        - Recite and demonstrate some non-pharmacologic ways to lessen pain. - Have normal respiratory rate.	Independent: - Provide comfort measures such as use of pillows under extremities and periodic wound cleaning on affected area. - Encourage and assist client to do deep breathing exercises. - Encourage mobilization of the left lower extremity. Assist with ROM exercises. - Discuss with client and relatives the importance of proper positioning and mobilization. - Teach client and significant other about the non-pharmacologic ways to lessen the pain. - Instruct client to report any improvement/exacerbation in pain experience. - Encourage verbalization of feelings about the pain. Dependent: - Administer medications, particularly analgesics, as prescribed.	To promote relief and wellness. Deep breathing exercises contribute to relief of pain To promote circulation and prevent excessive tissue pressure To maximize opportunities for self-control over pain manifestations.  Only the client can judge the level and distress of pain; pain management should be a team approach that includes the client.

Cues	Nursing Diagnosis	Goals and Objectives	Nursing interventions	Rationale	Evaluation
Objective: - Restlessness - Irritability -Presence of edema on lower extremities -Taut, shiny skin on lower extremities -Fluid intake greater than output Vital Signs: BP – 120/80 PR – 87 bpm RR – 32 breaths/min Temp – 37.4	Excess Fluid Volume related to impaired venous return secondary to immobility	Long Term: After 3 days of nursing intervention, the patient will exhibit decreased edema on lower extremities and stabilize fluid volume I&O. Short Term: After 8 hours of nursing intervention, the patient will be able to: -Identify causative factors affecting fluid retention. -Identify dietary intake and habits that contribute to fluid retention.	Independent: -Assist in periodic positioning every 2 hours. -Monitor I&O and amount of fluid intake from all sources and calculate fluid volume imbalance. - Periodically wash between skinfolds and dry carefully. -Protect edematous extremities from injury. -Relate causative factors affecting fluid retention. - Teach client and relatives about importance of proper positioning and keeping edematous feet elevated and clean. Dependent: - Administer Medications.	To prevent pressure ulcers To monitor kidney function and fluid retention To prevent injury and promote wellness To impart knowledge regarding present condition To promote circulation and prevent excessive tissue pressure