Scribd Logo
Upload

Welcome to Scribd!

  • Carlo

    Uploaded by

    John Carlo Sarinas Reyes
    14 views2 pages
    Cesar Ramirez, a 71-year-old male, presented with continued pain in his back, chest, head, and ears following earlobe surgery. On examination, he was conscious and conversing but displayed facial grimacing and guarding behaviors, reporting his pain level as an 8 out of 10. The nurse assessed that he was experiencing altered comfort due to postoperative pain and planned to alleviate his pain within two hours through interventions including medication administration, vital sign monitoring, pain education, and warm compress application, which successfully reduced his pain scale from 8 to 5 out of 10.

    Original Description:

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    DOC, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    Cesar Ramirez, a 71-year-old male, presented with continued pain in his back, chest, head, and ears following earlobe surgery. On examination, he was conscious and conversing but displayed facial grimacing and guarding behaviors, reporting his pain level as an 8 out of 10. The nurse assessed that he was experiencing altered comfort due to postoperative pain and planned to alleviate his pain within two hours through interventions including medication administration, vital sign monitoring, pain education, and warm compress application, which successfully reduced his pain scale from 8 to 5 out of 10.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    14 views2 pages

    Carlo

    Uploaded by

    John Carlo Sarinas Reyes
    Cesar Ramirez, a 71-year-old male, presented with continued pain in his back, chest, head, and ears following earlobe surgery. On examination, he was conscious and conversing but displayed facial grimacing and guarding behaviors, reporting his pain level as an 8 out of 10. The nurse assessed that he was experiencing altered comfort due to postoperative pain and planned to alleviate his pain within two hours through interventions including medication administration, vital sign monitoring, pain education, and warm compress application, which successfully reduced his pain scale from 8 to 5 out of 10.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    Patient: Ramirez, Cesar

    Age: 71 years old

    Subjective: “Nasaket pa din ang likod, dibdib, at ulo ko, pati na rin yung tenga ko
    gawa nang opera.” As verbalized by the patient.

    Objective:
     Conscious, awake and conversant

     Facial grimace

     Guarding behavior

     Pain scale of 8 out of 10 (1 is the lowest and 10 is the highest)

    Assessment: “Alteration in comfort related to pain secondary to surgery


    (debridement and repair of the left earlobe)

    Planning: “After two hours of nursing intervention, the patient will be free or
    alleviate pain.”

    Intervention:
     Assessed the pain(location, quality, radiation, severity, and timing of pain)

     Established nurse-patient interaction

     Vital signs checked and recorded

     With an IV fluid of PNSS x KVO

     Taught and demonstrated pain relief measures

     Applied warm compress on the surgical site

     Administration of medication (analgesic) to help reducing pain

    Evaluation: Goal Met – The client’s pain minimizes as a result of decrease in the
    pain scale from 8 out of 10 to 5 out of 10(as 1 is the lowest and 10 is the highest)
    Reyes, John Carlo S.

    BSN3S3G

    You might also like