Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective: Acute Pain After 15- 30 minutes of Independent: Goal met. After 15-30 minutes
“Sumasakit yung related to nursing interventions, the 1. Instruct the patient to do - Incisional pain after surgery in of nursing interventions, the
opera ko konti stimulation of patient will be able to deep breathing and cough the chest or abdomen often patient described pain from 4/10
ngayon, kasi nocireceptor cells understand and demonstrate exercises, provided that the inhibits normal respiratory down to 0/10. Also, the patient
kakainom ko lang of the abdominal ways on how to alleviate patient will splint the incision movements. Splinting can reduce was able to demonstrate ways to
ng gamot”. As area as evidenced pain. Also, within the 8- site. occurrence of muscle tension or alleviate pain; therefore,
verbalized by the by surgical hour shift, the patient will spasms, or undue stress on indicates that the interventions
patient wound on the left be able to experience incision. were effective.
lower quadrant. satisfactory pain relief as
Pain scale of 4/10 evidenced by decreased pain 2. Provide a quiet and calm - Pain may result in fatigue,
(10 as the highest) level of 0 from 4/10. environment which may result in exaggerated
pain. A peaceful and quiet
Objective: environment may facilitate rest.
 August 9,
2018: 3. Get rid of additional - Patients may experience an
Exploratory stressors and sources of exaggeration in pain or a
laparotomy, discomfort decreased ability to tolerate
enterolysis: painful stimuli if environmental,
extended left intrapersonal, or intrapsychic
hemicolectomy factors are further stressing
with Jackson them.
Pratt-drain.
 Midline 4. Assist the patient to a - To promote relief
incision: 15 cm comfortable position
 Right
hemiabdomen 5. Promote diversional - Increasing one’s concentration,
incision: 10 cm activities such as televisions these techniques help an
 12 days post- and listening to music individual decrease the pain
operative experience
 Has a guarding
behavior
 regarding the 6. Foresee the need for pain - Early intervention may
operative site relief decrease the total amount of
 Changes analgesic required.
position to
ease the pain 7. Acknowledge reports of - Pain can be aggravated with
 Slight facial pain immediately anxiety and fear especially when
grimace pain is delayed.

8. Provide comfort and support - To efficiently manage the pain,

measures and allow rest.

Dependent:

1. Administer analgesic - Effectiveness of pain

(Tramadol) as ordered by the medications must be evaluated
physician. individually because it is
absorbed and metabolized
differently by patients.

2. Notify the physician if - Combinations of medications

medication regimen is may be used on prescribed
inadequate to meet pain intervals.
control goal.

3. Evaluate and document the - Increasing or decreasing

patient’s response to dosage helps in self-management
analgesics, and assist in of pain.
transitioning or altering drug
regimen based on the patient’s
needs.