ASSESSMENT NURSINGDIAGNOSISPLANNING IMPLEMENTATION EVALUATION
³Makirot ang hiwa kosa tiyan, lalo na pagumuupo ako,´ asstated by the patient.8 out of 10 pain scaleObjective
± BP ± 110/90 mmHgPR ± 80 bpmRR ± 24cpmTemp ± 37.4°C
± Wound dressing intact
± Expressive behavior:irritability, facialgrimacingCovers the incisionsite (guarding behavior) No foul odor notedIncision site warm andreddened
related toabdominalincision asevidenced by8 out of 10 pain scaleWithin 20minutes of nursingintervention,the patient will be able to:
Participatein demo-nstratingtechniquesto relieve pain
erbalizeelimination/reduc-tion of pain from8 to 4.
INDEPENDENT DEPENDENT COLLABO- RATIVE
fter 20 minutesof nursingintervention, theclient:Demonstrated participation intechniques torelieve pain(proper positioning,resting, andfollowingnonpharmacologic pain regimens)
erbalizedreduction of painfrom 8 to 5Goal partiallymet.
ssess client¶s painscale (
to be able tomonitor progression of nursing interventions)
Monitor vital signsevery 4 hours
Provide calm, quietenvironment
Provide comfortmeasures such as back rub
to providenonpharmacologicalpain management)
Promote low Fowler¶s position (
low Fowler¶sposition reducesintraabdominalpressure, thus reducespain too)
Employ non- pharmacologic paindistraction such asmusic therapy, watchingtelevision, and talkingto SOs.
distraction of attention reduces painperception)
Teach client to eat fresh
dminister mefenamicacid q4°PO