CUES/NEEDS NURSING RATIONALE GOALS/ OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Independent:
Subjective Data: Acute pain related to Surgery Short term goal: After 1 hours of
destruction of tissue ↓ Assess for referred pain, as To help determine possibility of nursing
Patient complains of secondary to surgical Tissue damage After 1 hours of nursing appropriate. underlying condition interventions the
right sided chest procedure (ex lap/ ↓ interventions, the patient patient was able to
pain 7/10 TAHBSO) Unpleasant sensory will be able to report that report that the pain
and emotional the pain felt is Accept client’s description of pain. Pain is a subjective experience felt is
Objective Data: experience alleviated/controlled. Acknowledge the pain experience and cannot be felt by others. alleviated/controll
↓ and convey acceptance of client’s ed. 4/10: pain
• Facial Acute Pain Objectives: response to pain. scale
Grimace ↓
• Guarding Sudden or slow onset of • To assess Determine client’s acceptable level Pain varies with individual and
Behavior any intensity from mild etiology/precipit of pain. situation
to severe, constant ating
• HR:122 recurring with
contributory Explain to the patient that it is To help patient accept the
• RR:22 anticipated or
natural to feel pain in his condition. situation
predictable end and a factors
duration of less than 6
months • To evaluate Provide comfort measures, quiet
↓ client’s response environment and calm activities. Promotes relaxation and helps
Verbal reports of pain, to pain refocus attention.
autonomic responses Encourage relaxation technique and
(changes in vital • To assist client diversional activities such as Enables the patient to
signs) to explore focused breathing and listening to participate actively and
methods for music. enhances sense of control
alleviation/contr
ol of pain Dependent:
Reference:
Nurse’s Pocket • Relief of pain Administer pain medications as To relieve moderate to
Guide by Doenges, 4/10 prescribed by the physician moderately severe pain.
et.al., p. 498

Reference:
Nursing Careplans:;Guidelines
for Planning and
Documentaing Patient Care,
3rd Edition by Doenges,
Moorhouse and Geissler,pp.
1022-1023.