Professional Documents
Culture Documents
Subjective: Masakit yung tahi ko as verbalized by patient Objective: > Facial Grimace > Narrowed Focus > Incision site: wound: dry, no discharges noted. > V/S taken as follows, BB 110/80 RR 14 cpm PR 110 bpm Temp 38 C
Diagnosis
Acute Pain related to disruption of skin, tissue, and muscle integrity.
Planning
Goal: After 8 hours of nursing interventions, the patients pain will be relieved or controlled. Objectives: By the 2 hours of nursing intervention the client will; >Report pain intensity from 4-6 will decrease at 2-3 from 0-10 pain scale. >Participate in demonstrating techniques to relieve pain. >Have ability to manage situation.
Intervention
Independent: *Evaluate pain regularly noting characteristics, location, intensity (010 scale). *Review importance of nutritious fluid intake.
Rationale
Evaluation
After 8 hours of nursing interventions, the patients pain was relieved or controlled.
*Provides information about needs for effectiveness of intervention. *Provide elements necessary for tissue regeneration or healing. *May relieve pain and enhance circulation. *Relieves muscle and emotional tension.
*Reposition as indicated.
*Encourage use of relaxation technique like deep breathing exercise. Collaborative: *Administer analgesics or non steroidal anti