Assessment S


Nursing Diagnosis Acute pain

Objective A#ter ' !ours o# nursing intervention( t!e patient:

“ masakit ang paa ko” O: > iap!oresis > "it! guar ing be!avior >"it! pain an s"elling on R knee >"it! reports o# pain $%& BP: 130/90 Temperature : 37.8°C Pulse: 75bpm RR: 21bpm

Nursing Intervention +ital signs "ere monitore - . !ours until stable an ressing "as c!ecke /

Rationale Alterations #rom normal ma0 be signs o# in#ection/ 1oistene ressings are #avorable site #or microorganism to culture/ 2!is is to prevent iminis!e circulator0 an nerve #unction an control s"elling o# t!e site/ 2o re uce s"elling an prevent sti##ness t!e state activities must be one/ Decrease lung capacit0 an ecrease coug! e##icienc0 are pre isposing #actors to respirator0 in#ections/ 2o prevent #rom complications on t!e incision site( activities t!at ma0 e,ten t!e cut must be avoi e / 2!is is a vise in or er to prevent constipation an #ecal impaction/

Evaluation 3ain is re uce % controlle to a tolerable e,tent as verbali*e / Relieving met!o s an rela,ation tec!ni-ues are un erstoo an emonstrate /

)verbali*es minimi*e or A juste constricting controlle ban age an a vise #eeling o# pain to elevate le#t leg +erbali*es met!o s t!at provi e relie# Demonstrate use o# rela,ation skills an iversional activities

Instructe to o activities suc! as eep breat!ing e,ercise( coug!ing e,ercise an sitting e,ercises/

Note to avoi "eig!t bearing until allo"e /

Encourage to voi #reel0/

Enoug! rest an sleep 2!is promotes !ealing b0 "as also a vise / re ucing basal metabolic rate an allo"ing o,0gen an nutrients to be utili*e #or tissue gro"t!( !ealing an regeneration/ Intake o# pain reliever an antibacterial NSAID activit0 inclu es mo ulation o# 2)cell #unction( in!ibition o#

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