Acute Pain
Cues
Nursing Diagnosis
Subjective:
 “Medyo
makirot pa sa
may sugat
pero minsan
na lang,” as
verbalized by
the patient.
Alteration in comfort:
Acute Pain at LLE
related to tissue and
nerve trauma as
manifested by verbal
report of pain and
limited movement of
LLE.
Objective:
 With
amputated
LLE
 Verbal report
of pain with a
scale of 2 (1lowest, 10highest)
 Limited
movement of
LLE
Background
Knowledge
Acute pain is an
unpleasant
sensory
and
emotional
experience arising
from actual or
potential
tissue
damage; sudden
or slow onset of
any intensify from
mild to severe
with
an
anticipated
end
and a duration of
less
than
6
months.
Goals / Objective
Long Term:
To
facilitate
maintenance
regulatory
mechanism
functions.
the
of
and
Nursing
Intervention
Rationale
1. Assessed
for
referred pain using a
pain rating scale.
2. Monitored
signs.
vital
Short Term:
At the end of the
shift, the reported
pain will decrease
from 2 to no pain at
all.
3. Encouraged use
of
relaxation
techniques
like
focused breathing.
Evaluation
1. This may help Goal met.
determine
the
possible underlying  The
reported
condition.
pain
was
relieved, from a
2. To
have
a
scale of 2 to 0,
baseline data and
by the end of the
monitor
for
any
shift
through
irregularities.
proper
positioning of the
3. This can help
affected limb with
manage or control
the assistance of
pain.
SOs upon every
movement.
4. Encouraged
significant others to
use
comfort
measure
like
therapeutic
touch
and communication.
4. This promotes 
cooperation
and
helps divert the pain
felt by distracting the
attention to pain and
thus
reducing
tension.
5. Encouraged
adequate rest.
5. This
can
promote
wellness
and reduces fatigue.
6. Observed
for
any untoward S/Sx.
6. To prevent any
other complications
and to implement
immediate action.
The patient, as
well as the SOs,
has
demonstrated
the
use
of
relaxational and
diversional
activities.