Acute Pain r/t post op surgical incision | Pain | Pain Management

Nursing Care Plan

Cues Subjective: The client verbalized -“masakit talaga yung tahi ko, nahihiripan ako gumalaw” -“hindi ko magawa mapa dede anak ko magisa dahil sa sakit” -“siguro nasa ‘6’ (10 highest) ang sakit niya.” -“hindi talaga ako makagalaw dahil sa tahi, nakakinis nga eh” Objective: -presence of grimace -on guarding position during the interview -pale Nursing Diagnosis Acute pain related to post-op surgical incision Analysis The client is experiencing pain due to the episiotomy done to her after the CS operation. Pain is a typical sensory experience that may be described as the unpleasant awareness of a noxious stimulus or bodily harm. Individuals experience pain by various daily hurts and aches, and occasionally through more serious injuries or illnesses.
(http://en.wikipedia. org /wiki/pain)

Goal and Objectives Goal: After 12hours shift, the client’s pain will be lessened. Objective: > After 5 minutes, the client will verbalize the characteristic and location of pain.

Interventions

Rationale

Evaluation The client’s pain was lessened.

DEVELOPMENTAL : Perform a comprehensive assessment of pain to include location, characteristics, onset, duration, frequency, quality, intensity or severity, and precipitating factors of pain. DEVELOPMENTAL : Teach the use of nonpharmacologic techniques: -deep breathing technique

Pain is a subjective experience and must be described by the client in order to plan effective treatment.

The client was able to verbalize to characterize and locate the pain.

> After 10 minutes client will be able to perform pain management: -deep breathing technique

The use of noninvasive pain relief measures can increase the release of endorphins and enhance the therapeutic effects of pain relief medications.

The client was able to perform deep breathing exercise.

The client was

-RR: 24 breath/min

> On the given time, administer pain reliever to the client.

FACILITATIVE: Provide optimal pain relief with doctor’s prescribed analgesics.

Each client has a right to expect maximum pain relief. Optimal pain relief using analgesics includes determining the preferred route, drug, dosage, and frequency for each individual. Medications ordered on a prn basis should be offered to the client at the interval when the next dose is available.

able to take her due med.

> After every 4 hours, the client’s vital signs will be monitored.

SUPPLEMENTAL: Monitor client’s vital signs including: blood pressure, respiratory rate, pulse rate and temperature. Assessment of vital signs is an important component of the physical therapy examination and should be included in the examination of all patients. Knowledge of vital signs allows the therapist to understand a patient's physiologic status and is helpful in determining appropriate goals.

The client’s vital signs were monitored.

Efficiency The time, materials, and human resources were used economically

Adequacy The numbers of interventions were sufficient.

Appropriateness The interventions were suitable to the client’s situation. Acceptability The interventions, setting, and timetable were realistic to the client’s situation.

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