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