Você está na página 1de 2

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Alteration in comfort: After 1 hour of nursing 1. Established 1. To get the GOAL MET
- Cannot sleep as Acute pain intervention the patient rapport cooperation of the
claimed will demonstrate patient
relaxation skills to relieve
Objective: pain
2. Monitored and 2. Obtain baseline
(+) flank pain in ....... At the end of the shift, recorded vital signs data
patient will be able to
(+) body weakness as
demonstrate pain control 3. Performed a 3. To be able to
claimed
measures. comprehensive compare changes
Pain scale: 4/10 assessment of from previous
pain(location on report. To rule out
set, characteristics worsening
and frequency) underlying
condition or
developing
complication

4. Assessed patient 4. To acknowledge


description of pain the pain
experience convey
acceptance of
client response to
pain
5. Encouraged use of
relaxation exercise 5. This is a form of
such as focus relaxation
breathing technique that
help decrease level
6. Encouraged of pain
verbalizations of
feelings about the 6. To allow outlet for
pain emotions and
enhance coping
mechanism