Nursing Diagnosis

Goal

Intervention

Rationale

Evaluation

Acute pain related to physical injury as eveidenced by PR= 125, RR=24, lacerated cound on the submandibular area, rated pain scale of 8 out of 10 as the highest. Client verbalized, “sakit akon pilas, kay nag banda ang bato paghaboy ko”

After 4 hours of effective nursing intervention, client will manifest relief of pain.

Independent:

1. check vital signs

2. Clean the affected site.

3. Apply moderate pressure and cold compress on the affected site.

Dependent:

1. administer analgesic as ordered by the physician
2. assist in suturing of wound

Collaborative:

1. refer to Xray department.

- serves as baseline data. Changes indicates increase in pain.

- To reduce risk off infection.

- To decrease bleeding

- analagesic decreases pain

- suturing of wound will close the affected site and may reduce risk of infection and other further complications.

- to determine if there are any fracture or problem related to the cause of injury.

Goals met. Client manifested relief of pain. No complaints heard from the client.