Assessment Cues Nursing Diagnosis Pathophysiologic/ Desired Outcomes Nursing Intervention Rationale Evaluation

Schematic Diagram
Independent Independent
Predisposing factors: SHORT TERM: Intervention: Intervention: SHORT TERM:
Subjective Cues: Acute pain: head, - Infections — such as After 8 hours of 1. Obtain client’s 1. To rule out After 8 hours of
“Kasakit sang ulo ko. throat, sinus related colds, flu or sinusitis Nursing assessment of pain to worsening of Nursing
Ang mata ko pa gid to inflammation of - Deviated nasal septum Intervention, the include location, underlying Intervention, the
kag ilong” as the nose - Nasal polyps patient and characteristic, onset, condition/develop patient and
verbalized by the significant other frequency, quality, ment of significant other
patient. Definition: Precipitating factors: will be able to: intensity, and complications. will be able to:
- Regular exposure to precipitating factors. (NANDA 11th ed.,
Pain scale: 7/10 as 0 is The International pollutants such as cigarette 1. Report the Reassess each time pain is p. 500) 1. Report the
the lowest and 10 is Association for the smoke characteristic of pain in reported. characteristic of
the highest. With the Study of Pain (IASP) ↓ terms of perceived 2. To confirm if pain in terms of
pain characteristics of defined pain as “an intensity using pain 2. Observe nonverbal observations may perceived intensity
severe pain. unpleasant sensory and S/S: scale and description of cues/pain behaviors. or may not be using pain scale and
emotional experience - Pain, tenderness and pain. congruent with description of pain.
associated with actual swelling around eyes, 2. Perform pain verbal reports or (GOAL MET)
Objective Cues: or potential tissue cheeks, nose or forehead management such as may be only 2. Perform pain
Patient manifested: damage, or described guided imaging and indicator present management such
- facial grimace in terms of such ↓ deep breathing for 5-10 when client is as guided imaging
- verbal report of acute damage.” minutes, 3-4 times a unable to and deep breathing
pain Acute pain: head, throat, day. verbalize. for 5-10 minutes, 3-
- guarded and Wayne, G. (2020, sinus related to 3. Have adequate (NANDA 11th ed., 4 times a day.
protective behavior September 06). Acute inflammation of the nose continuous rest for 6-8 p. 500) (GOAL MET)
- swelling or redness Pain: Nursing hours. 3. Have adequate
around the eyes Interventions and Care 3. Monitor skin and color 3. These are continuous rest for
- forehead swelling Plan. Retrieved LONG TERM: temperature and vital usually altered in 6-8 hours.
- sleep disturbance December 01, 2020, After 32 hours of signs. acute pain. (GOAL MET)
from nursing intervention, (NANDA 11th ed.,
https://nurseslabs.com/ the patient will be p. 501) LONG TERM:
Strengths: acute-pain/ able to: After 32 hours of
- good family support 4. Demonstrate and 4. To promote nursing
- strong faith and 1. Maintain a pain level encourage deep breathing nonpharmacologi intervention, the
spirituality of 3 or less during exercises. cal pain patient will be able
remaining of hospital management. to:
Weaknesses: stay. (NANDA 11th ed.,
- poor knowledge 2. Demonstrate the use p. 501) 1. Maintain a pain
about current of appropriate level of 3 or less
condition diversional activities 5. Provide comfort 5. To promote during remaining of
- situational fear and and relaxation skills. measure (touch, nonpharmacologi hospital stay.
anxiety 3. Improve feeling of repositioning every 2 cal pain (GOAL MET)
- lack of resources control as evidenced by hours), quiet environment management. 2. Demonstrate the
which affects health verbalizing a sense of and calm activities. (NANDA 11th ed., use of appropriate
related decision control over present p. 501) diversional
making situation and future activities and
- negative views outcomes within 32 6. Encourage use of 6. To distract relaxation skills.
towards medical hours of nursing relaxation and diversional attention and (GOAL MET)
interventions interventions. techniques such as reduce tension. 3. Improve feeling
focused breathing, (NANDA 11th ed., of control as
CDs/tapes, TV/radio, etc. p. 501) evidenced by
verbalizing a sense
7. Encourage adequate 7. To prevent of control over
rest periods. fatigue. (NANDA present situation
11th ed., p. 502) and future
outcomes within 32
Dependent Intervention: Dependent hours of nursing
1. Administer analgesics, Intervention: interventions.
as indicated and notify 1. To maintain (GOAL MET)
physician if regimen is acceptable level
inadequate. of pain. To
maintain
acceptable level
of  pain. (Nurse’s
Pocket Guide, 9th
ed. by Doenges,
 Marilynn, et.al.,
p. 368)

Collaborative Collaborative
Intervention: Intervention:
1. Assist with 1. To determine
laboratory/diagnostic changes
studies as indicated. indicative of
healing/infection/
complications. To
identify
causative/
precipitating
factors. (Nurse’s
Pocket Guide, 9th
ed., by Doenges,
Marilynn, et.al.,
p.70)