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Assessment Diagnosis Planning Intervention Rationale Evaluation Subjective: Short Term Goals: Independent: Short Term Goals

The document provides an assessment, diagnosis, planning, intervention, rationale and evaluation for a client experiencing acute pain in the left leg rated at 7/10. Short term goals include the client being able to take personal action to control pain, verbalize pain relief methods and demonstrate relaxation skills within 2-3 hours. Interventions include assessment, monitoring, deep breathing, diversional activities and elevating the leg. The rationale indicates a need to alleviate pain and promote rest. After 2-3 hours, the client was able to control pain and identify relief methods, partially meeting the short term goal. Long term goals include reporting a decreased leg pain level to 5/10 within 1-2 days.

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kyaw
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892 views1 page

Assessment Diagnosis Planning Intervention Rationale Evaluation Subjective: Short Term Goals: Independent: Short Term Goals

The document provides an assessment, diagnosis, planning, intervention, rationale and evaluation for a client experiencing acute pain in the left leg rated at 7/10. Short term goals include the client being able to take personal action to control pain, verbalize pain relief methods and demonstrate relaxation skills within 2-3 hours. Interventions include assessment, monitoring, deep breathing, diversional activities and elevating the leg. The rationale indicates a need to alleviate pain and promote rest. After 2-3 hours, the client was able to control pain and identify relief methods, partially meeting the short term goal. Long term goals include reporting a decreased leg pain level to 5/10 within 1-2 days.

Uploaded by

kyaw
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Acute Pain related Short term goals: Independent: Short term goals
“Masakit yung kaliwang to musculoskeletal At the end of 2 to 3  Perform an assessment of pain  Indicates need for After 2 to 3 hours of
paa ko” as verbalized by impairment as hours of nursing to include location, effectiveness of interventions nursing interventions, the
the client evidenced by interventions, the characteristics, onset/duration, and may sign of development client was able to:
Pain Scale: 7/10 facial grimace, client will be able to: frequency, and severity. to the status of the client. • Take personal action to
restlessness,  Take personal action  Monitor vital signs (blood  To evaluate client’s response control pain
Objective: guarding behavior, to control pain pressure, pulse, respiration). to pain • Verbalize method that
• Vital signs: irritability, and  Verbalize method  Instruct the client to do deep provide relief
o BP: 140/90mmhg Blood pressure of that provide relief breathing exercise  To alleviate or control the • Demonstrate use of
• Facial Grimace 140/90mmhg,  Demonstrate use of  Encourage diversional pain relaxation skills and
• Restlessness relaxation skills and activities (E.g. TV/Radio,  To divert and lessen the pain diversional activities
• Guarding behavior diversional activities socialization with others, felt by the client. Goal partially met
• Irritable listening to music)
Long term goal:  Elevate and support the  Promotes venous return,
At the end of 1 to 2 injured extremity using decreases edema, and may
days of nursing pillows or rolls. reduce pain. Long term goal:
interventions, the  Create a calm and comfortable After 1 to 2 days of
client will be able to: environment.  To promote proper rest nursing interventions, the
 Report and client was be able to:
demonstrate a  Report and
decrease in leg pain Dependent: demonstrate a
from 7/10 to 5/10. • Administer NSAIDs as decrease in leg pain
ordered by the Physician from 7/10 to 5/10.
Goal partially met
 To maintain acceptable level
of pain

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