CUES NURSING SCIENTIFIC PLANNIN IMPLEMENTATION SCIENTIFIC EVALUATION

DIAGNOSIS EXPLANATION G RATIONALE

Subjective: Acute pain related An incision is a cut Short term: Independent Short term:
“Masakit yung to surgical through the skin that is After 4 -Monitor vital signs -Serves as baseline (Partially Met)
tahi ko lalo na incision secondary made during surgery. hours of data of the patient After 4 hours of
kapag to cesarean birth One-fifth of women who nursing nursing
gumagalawako” as evidenced by undergo cesarean intervention, -Perform assessment -Indicates need for intervention,
pain scale of 4 out delivery will experience the patient of pain, effectiveness of the patient was
Objective: of 10 and facial severe pain in the acute will characteristics, intervention and signal able to
>FacialGrimace grimace postoperative period, experience duration, severity and development of experience
with pain scale of increasing their risk of lesser pain location complications lesser pain and
4 out of 10 (1 developing chronic pain and above a above tolerable
lowest, 10 highest) and postpartum tolerable -Encourage to have -It can prevent as evidenced by
>Protective depression, and pain as deep breathing exhaustion and help pain scale of 2
gesture to avoid negatively impacting evidenced exercises relaxation out of 10 and
pain in incision breastfeeding and by pain slight
site newborn care. scale of 2 -Provide comfort -To alleviate pain irritability
>Expressive Acute pain, which out of 10 measures such as by promoting
ehavior such as usually occurs in and slight repositioning or quiet non- pharmacological Long term:
sighing response to tissue injury, irritability environment pain management (Partially Met)
>Limited results from activation of After nursing
movement peripheral pain receptors Long term: >Instruct the patient >To distract attention intervention the
>Irritability and their specific A delta After to use relaxation and reduce tension patient was be
and C sensory nerve nursing techniques and able to be free
fibers (nociceptors). intervention encourage diversional from pain as
Chronic pain related to the patient activity such as evidenced by
ongoing tissue injury is will be able listening to music, patient
presumably caused by to be free watching television reporting
persistent activation of from pain and socialization with relieved pain
these fibers which can be as others and
evidenced by the pain evidenced demonstrate
scale of patient and by patient -Instruct the mother -To have early relaxation
protective gestures to reporting to report any pain treatment and techniques such
avoid pain in the incision relieved medication as deep
site. pain and
Smith, G. (2018), demonstrate -Increase fluid intake -prevent dehydration breathing and
Wound care and relaxation imaging.
dressings. Clinical techniques. -Encourage to eat -food rich in
Nursing Skills: Basic to nutritious food rich in carbohydrates for
Advanced Skills. 9th ed. protein and energy and protein for
New York, NY: Pearson; carbohydrates pain
2016:chap 25.
Collaborative/Depend
ent
Administer ketorolac -analgesia to relieve
as ordered by pain
physician’s order