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Acute Pain Assessment Subjective: Masakit ang tahi ko.

stinging pain @ right lower quadrant radiating to the sides of the abdomen with pain scale of 7/10, occurring everytime the patient tries to move Objective: -Facial grimace noted -Guarding behavior noted -incised wound at approx. 10 cm. on the right lower quadrant noted. VS: T- 36.8 P- 78 bpm R- 21 bpm BP- 140/80 Diagnosis Planning Acute pain related to STG: surgical incision At the end of 2 hours nursing intervention, the patients reported pain Definition: will reduce as evidenced Unpleasant sensory by decrease in pain scale experience arising from from 7 to 5. actual tissue damage. LTG: At the end of 3 days Background Theory: nursing intervention, will be able demonstrate It is stated in the theory ways to reduce pain and of Virginia Henderson cope with pain such as that moving and focused breathing and maintaining a desirable diversional activities position is one of the 14 such as imagery or basic needs to attain listening to music. homeostasis. In our case, the patient feels pain whenever she moves. Therefore, the nurse must provide necessary actions to address the problem. Evaluation STG: Hindi na masyadong 1. Position in a high masakit yung tahi ko. Fowlers position. To provide comfort Pain scale was and minimize pain. decreased from 7 to 5. 2. Monitor VS. To obtain baseline data and to assess the effectiveness of the nursing interventions. BP of 110/80. Intervention Independent:

LTG: Was able to do focused breathing and diversional activities like listening to music and imagery to 3. Instruct and cope with the pain felt. encourage use of relaxation techniques such as focused breathing, imagery and listening to music. To divert attention from pain. 4. Instruct to place pillow against her abdomen when coughing or moving. To minimize pain by eliminating

excessive tissue pressure on the site of incision. 5. Instruct to avoid strenuous exercise and activities. To prevent bleeding of the surgical incision made from the operation. 6. Encourage to have short walk everyday as a form of exercise. To promote blood circulation and faster healing of the incision. 7. Instruct to clean and change wound dressing at least once a day. To facilitate faster healing of the wound. Dependent: 8. Administer Nubain as prescribed. To reduce pain.

Risk for Infection Assessment S:





Risk for infection r/t STG: Independent: STG: surgical incision At the end of 8 hours Dressing dry and none secondary to nursing interventions, 1. Wash hand before intact. and after contact. herniorrhaphy the client will be free of O: Handwashing is Surrounding area free infection as evidenced the universal from by: any sign of flat on bed precaution to infection. a. clean and dry Definition: prevent spread of wound dressing at with surgical incision microorganisms VS : of approximately 10 cm At increased risk for incision site; through contact. b. surrounding area T- 37 long at RLQ of abdomen being invaded by 2. Monitor V/S and of the incision is free of P- 75 bpm pathogenic organisms. assess site for any dressing noted; dry redness, swelling, or R- 20 bpm signs of infection and intact purulent discharge and BP- 110/70 such as swelling and c. normal vital VS: pain at site. Background Theory: signs. An elevated LTG: T- 36.8 According to Betty LTG: temperature, pulse No signs of infection Neuman, the focus of and respirations noted on patient. At the end of 2 days P- 78 bpm nursing care is to assist nursing indicate systemic interventions, individuals, families and the client will remain free infection; heat, R- 21 bpm groups in attaining and from any signs of swelling and pain maintaining maximal infections. BP- 110/80 indicate local level of total wellness infection. through the primary, 3. Use aseptic technique secondary and tertiary during dressing levels of prevention. change and wound care. In relation to our To prevent the patient, he is at risk for introduction of acquiring infection pathogens. because of the surgical

incision on his abdomen. As nurses, our responsibility includes doing appropriate interventions that will help reduce the possible complications that can be brought about by his present condition.

4. Instruct patient and SO not to touch site. To avoid transmission of microorganisms through touching. 5. Encourage sufficient nutritional intake such as foods rich in fiber and protein. Adequate nutrition is essential for the promotion of the immune system cells and the repair of damage body tissues. 6. Educate client and SO on the signs and symptoms of infection: elevated temperature, redness, swelling of the incision site and purulent or foulsmelling discharges and when to report them to healthcare provider. Educating both the client and family helps assist in early recognition of adverse signs and

symptoms, and when to report them to healthcare provider. Dependent: 7. Administer antibiotics such as ampicillin as prescribed. Antibiotics inhibits bacterial cell wall synthesis causing cell death.