KEY ISSUES DESIRED INDEPENDENT ACTUAL

OUTCOME INTERVENTION OUTCOME

Date identified: Within the 3 days 1.Assessed March 5, 2015
March 3, 2015 of student nurse- patient’s pain
1. Acute Pain patient including type, After 3 days of
related to interaction, location and student nurse-
disruption of skin patient will be intensity. Used a patient
and tissue able to report a 10-point rating interaction:
secondary to pain scale from scale. The patient
surgical procedure 6/10 to less, R:Assessment reported lesser
S/P Total perform relaxation provides clues to pain scale of pain
Abdominal techniques such as underlying cause scale 5/10 with 10
Hysterectomy deep breathing of pain and as the highest and
Right Salpingo exercises and provides a 1 as the lowest
Oophorectomy as diversional baseline for The patient was
manifested by activities ( reading developing able to perform
gnawing pain at newspaper or appropriate pain deep breathing
the epigastric to listening to music); relief strategies exercises
hypogastric region use of splinting (Potter & Perry, The patient was
aggravated by techniques when 2009). splinting the
sudden movement moving, abdominal area
and relieved by ambulating or 2.Accepted client’s upon movement
rest with a pain coughing. description of and ambulating.
scale of 6/10, with pain. Acknowledge The patient
10 as the highest the pain verbalized “Wala
and 1 as the experience and naman kaayo
lowest, convey acceptance sakit, day. Ready
characterized by of client’s najud ko muuli.”
guarding behavior response to pain.
of affected site, R: Pain is a
facial grimacing, subjective
irritable, quiet and experience and
verbalization of cannot be felt by
“Sakit kung others (Potter &
mulihok.” Perry, 2009).

SCIENTIFIC BASIS: 3. Noted client’s

Post-operative age and current
pain is associated condition affecting
with actual or ability of the client
potential tissue to report pain
damage as a result parameter.
to surgical R:different
procedure developmental
performed. An levels and
actual or potential diseases may
skin and tissue manifest different
damage will serve pain characteristic
as stimuli that (Doenges, 2008).
would activate 4. Noted client’s
nociceptors attitude towards
responsible for and use of pain
sending electrical medication.
impulse to the R: Negative view
spinal cord via of pain can
peripheral nervous aggravate the
system to the problem (Potter &
brain, where it is Perry, 2009).
interpreted as an
unpleasant 5.Encouraged
sensory or verbalization of
emotional feelings.
experience and a R: Verbalization of
very personal feelings can
sensation. reduce anxiety
Behavioral and fear thereby
characteristics reduces
associated with perception of
pain would include intensity of pain
assuming a and to receive
position that prompt evaluation
minimizes pain; and effective
moans, sighs, treatment.
grimaces, clenches (Luxner, 2005)
the jaw or fist,
becomes quiet or 6. Advised to use
withdraws from pain relief
others; crying, measures such as
exhibiting deep breathing
restlessness or exercises and
protecting diversional
affected area or activities such as
remain reading
motionless. newspaper,
Reference: listening to music
Hinkle, J. L. & or talking to S.O.
Cheever, K. H. R: Deep breathing
(2014). Brunner is an effective
and Suddarth’s source of pain
Textbook of control as it
Medical Surgical relaxes and
Nursing (13th ed.). relieves muscle
Philadelphia, PA: tension and
Lippincott promotes
Williams and relaxation of
Wilkins. mind. Diversional
activities help to
distract patient
from focusing on
the perception of
pain (Kozier,
2008).

7.Encouraged
adequate rest
periods.
R: Resting helps to
lessen pain as it
relaxes muscles
from being used
relieves muscle
tension. (Kozier,
2008)

8.Responded
immediately to
pain complaints.
R: To decrease
anxiety of the
patient and to
show concern to
patient’s welfare.
(Potter & Perry,
2009)

9.Observed
nonverbal cues.
R: Observations
may or may not be
congruent with
verbal reports or
may be only
indicated to
present when
client is unable to
verbalize. (Kozier,
2008)

10.Provided
comfort measures
such as giving of
cold compress,
quiet
environments and
calm activities.
R: To promote
non-
pharmacologic
pain management
(Kozier, 2008)

Collaborative
Interventions:
1. Tramadol +
Paracetamol 37.5
mg/325 mg /tab 1
tab q 8H po
R: To reduce pain
of patient.