Agcol, Jael Lorenz G.

BSN 2A 429- H ASSESSMENT Subjective Data: NURSING DIAGNOSIS

NCP Submitted to: Maam Rosalie Onayan PLANNING After 4 hours of nursing intervention , the pain felt by the patient will decrease from 7 to 4. NURSING INTERVENTION RATIONALE EVALUATION After 4 hours of nursing intervention, the pain felt by the patient decreased from 7 to 4.

Acute pain related to surgical Masakit ang incision puson ko, as secondary to verbalized by lower right the patient. caesarian section. Objective Data: > 110/80 mmHg >37.1 C > Pulse rate: 82 bpm > RR: 18 bpm > grimaced face > pain scale of 7/10 Definition: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to sever with an anticipated or predictable end and a duration of less than 6mos. Reference: Nurse's Pocket Guide 11th edition

> Monitor skin > These are color, temp and usually altered vital signs. in acute pain. To provide basis. > Note client's > To report age/developparameters. mental level and current condition affecting ability. > Note location of surgical procedures, as this can influence the amount of postoperative pain experienced; for example, vertical/diagona l incisions are more painful than transverse or S-shaped. > Obtain client's assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity and precipitating factors. > Presence of known or unknown complication(s) may make the pain more severe than anticipated.

> To rule out worsening of underlying condition or developing complications.

Continuation

NURSING INTERVENTION > Observe non verbal cues/pain behaviors > Note when pain occurs. > Promote comfort measures. > Encourage adequate rest periods. > Encourage breathing exercises.

RATIONALE > Observations may/may not be congruent with verbal reports or may be only indicator present when client is unable to verabalize. > To medicate appropriately > To promote non pharmacological pain management. > To prevent fatigue. > Promotes maximal lung expansion and aids in clearing airways.