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ASSESSMENT Subjective: Pain Scale: 9 out of 10 in the right lower occipital (10 being the highest, 1 being the

e lowest) Objective: Facial gri ace !"pressive behavior (irritabilit#) Slowe$ ove ent %S as follows: &' () P*'99 **' +, -P'1,0./0

DIAGNOSIS 0 e$iate cause: 1cute Pain r.t to tissue trau a

obstruction of the common blood on the brain Inflammation and swelling depress the free nerve endings Acute Pain.

INFERENCE

PLANNING 2oal: 1fter an ) hour shift of nursing interventions, the client3s pain is relieve$ an$ controlle$4 Objectives: 1fter nursing interventions,: 14 the client will be able to report the characteristic of pain4 +4 the client will be able to perfor pain anage ent4

Interventions 14 Obtain client3s assess ent of pain to inclu$e location, characteristic, onset, fre5uenc#, 5ualit#, intensit#, an$ precipitating factors4 *eassess each ti e pain is reporte$4 +4 Observe nonverbal cues. pain behaviors4 (4 6onitor s7in an$ color te perature an$ vital signs4 ,4 8e onstrate an$ encourage $eep breathing e"ercises4

Rationale 14 &o rule out worsening of un$erl#ing con$ition. $evelop ent of co plications4 (<1<81 11th e$4, p4 900) +4 Observations a# or a# not be congruent with verbal reports or a# be onl# in$icator present when client is unable to verbali=e4 (<1<81 11th e$4, p4 900 (4 &hese are usuall# altere$ in acute pain (<1<81 11th e$4, p4 901) ,4&o pro ote nonphar acological pain anage ent4 (<1<81 11th e$4, p4901) 94 &o pro ote nonphar acological pain anage ent4 (<1<81 11th e$4, p4901) :4 &o $istract attention an$ re$uce tension4 (<1<81 11th e$4, p4 901) /4 &o $istract attention an$ re$uce tension4 (<1<81 11th e$4, p4 901) )4 &o prevent fatigue44

Evaluation 2oal partiall# et4 &he client3s pain was relieve$ an$ controlle$ b# client3s verbali=ing Pain scale of /.104

(4 the client will be able to rest an$ sleep continuousl#4

94 Provi$e co fort easure (touch, repositioning ever# + hours), 5uiet environ ent, an$ cal activities4 :4 !ncourage use of rela"ation techni5ues such as focuse$ breathing, ;8s.tapes4 /4 !ncourage $iversional activities (&%, ra$io) )4 !ncourage a$e5uate rest perio$s4

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