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Nursing Diagnosis # 1 Acute Pain Related to Abdominal Incision.

Nursing Diagnosis # 1 Acute Pain Related to Abdominal Incision.

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Published by: jhunanax on Dec 11, 2009
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01/28/2013

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NursingDiagnosis # 1NeedDesiredOutcomeNursing InterventionRationaleEvaluationModificationRationale
Acute painrelated toabdominalincision.
Subjectivecues:
“Sakit pa perohindi na kaayo”as verbalizedby the patient.
Objectivecues:
Temp: 37.5
°
C
PR: 63 bpm
RR: 19 cpm
BP: 120/80mm Hg
Rated painas 4 to 6 outof 0 to 10pain scale.
Painincreaseswhenmovesvigorously
Incision site:PHYSIOLOGICNEEDWithin the 8hours of duty,the patientshould be ableto:
Reportpain isrelieved or controlled.Painintensity 4to 6 willdecreaseat 2 to 3from 0 to10 painscale.INDEPENDENT
EEstablishrapport to thepatient
MMonitor Vitalsigns
PPerformbedside care
OObserve anddocumentlocation,severity andcharacter of pain.
To easily gaincooperation form the patient To have baselinedata and for comparison for futuredataTo enhance patient’sself esteem and to provide comfort tothe patient 
GOAL MET.The patientwas able toreport thecharacteristics of pain(location: righthypochondriac region,scaled painas 4 to 6 outof 0 to 10 painscale, able toverbalizedpain felt uponpressureapplied on thesite). Able toverbalizefeeling of comfort after repositioningwas done.Nomodificationsneeded
 
Wound: dry, nodischargesnoted Dressing an plaster wereclean and fully covered theincision site.No foul odor noted on thesite
.
BACKGROUNDKNOWLEDGE:
Pain is definedas unpleasantsensory andemotionalexperiencearising fromactual opotential tissuedamage odescribed interms of suchdamage.(InternationalAssociation for the Study oPain); sudden
PPromotebedrest,allowing patientto assumeposition of comfort
CControlenvironmenttemperature
By getting thefollowing information,we are asssitting indifferentiating causeof pain and providing information about disease progression/resolution, development of complications and effectiveinterventions.This also provides anobjective means of evaluating thesubjective experinceof the patient.Bedrest in low-fowler’s posiitonreducesintraabdominal  pressure; however, patient will naturally assume least painful  position.Cool surrounding aids in minimizing 
 
or slow onset of any intensityfrom mild tosevere with ananticipated or predictable endand a durationof greater than6 months.(Nurse’sPocket Guide)The patient,report pain feltat the plantaregion of leftfoot.. Thisaffects theability of thepatient to takeadequate restfor fastrecovery. Withthis, it needsimmediatenursinginterventions toatleast reduceor lessen thepain.
TTake time to listento and maintainfrequent contact withpatient andencourage toverbalize felelingf.
dermal discomfort.This is helpful inalleviating anxiety and reducing attention which could aid in relieving pain.Verbalization of feeling can reduce perception intensity of pain. Thus would facilitate in providing comfort and relaxation.
.Nursing Diagnosis #2NeedDesired OutcomeNursingInterventionsEvaluationstatementNursingmodificationsRationale

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