Admitting Diagnosis: Post-Debridement with Jackson Pratt Drain

Assessment Nursing Diagnosis Rationale Desired Outcomes Nursing Interventions Justifications Evaluation

Actual/Abnormal Acute pain related Multiple hack After 3 hours of After 3 hours of nursing
cues to presence of wound at the nursing interventions, the patient was
 Patient complained, postoperative temporoparietal interventions, the able to:
“Gasakit ang ulo surgical incision as and neck area patient will be able
ko” evidenced by due to to:
 (+) Guarding verbal report of mechanical 1.)Report pain is 1.1 Assess for referred 1.1 To help 1.) Goal met. Verbalized,
behavior of putting pain at head part, trauma relieved/ pain, as appropriate determine “waay naman gasakit kag
his arm on his head guarding behavior, controlled. possibility of gahubag akon ulo”. No
part and facial mask underlying signs of inflammation on
 Has a facial [beaten look]. Undergone condition or the surgical wound such
expression like that surgical organ. as presence of erythema
of a beaten look Definition: intervention of 1.2 Obtain client 1.2 To rule out and swelling.
face Unpleasant sensory debridement assessment to pain worsening of
 Patient seen and emotional with Jackson including location, underlying
changing position experience arising Pratt drain characteristics, condition/
every now and then from actual/ onset/duration, intensity, development of
 Pain scale of 6 potential tissue precipitating and complications.
damage or Inflammation of aggravating factors.
Risk/Risk Factors described in terms surgical wound Reassess each time pain
 Presence of of such damage as part of healing occurs/is reported.
Jackson Pratt drain (International process /
in the head Association for the wearing off of 1.3 Monitor skin color/ 1.3 Which are
Strengths study of Pain); anesthetic temperature and vital usually altered
 Strong family sudden/slow onset substances signs in acute pain
support of any intensity
 Good compliance from mild to severe
to treatment and with an anticipated Acute pain 2.)Follow 2.1 Administer analgesics, 2.1 To maintain 2.) Goal met. Complied in
medications or predictable end related to prescribed Paracetamol and acceptable level of taking medications on
and a duration of postoperative pharmacological Celecoxib, as indicated to pain. Notify time such as Paracetamol
less than 6 months. surgical incision regimen. maximum dosage as physician if 500 mg 1 tab PO PRN
 needed. regimen is and Celecoxib 200 mg 1
Source: Source: Medical- inadequate to meet cap OD for pain relief
Doenges, M.E, et. Surgical Book pain control goal.
Al. Nurse’s Pocket Edition 16 by
Guide Edition 11. Williams and 2.2 evaluate/ document 2.2 increasing/
F.A. Davis Wilkins. client’s response to decreasing dosage,
Company. analgesia, and assist in stepped program
Philadelphia, transitioning/ altering drug helps in self-
Pennsylvania. regimen, based on management of
3.) Goal met. Demonstrated
2008. individual needs. pain.
use of relaxation skills
and diversional activities
3.)Demonstrate use 3.1 provide comfort 3.1 to promote non-
by elevating his injured
of relaxation measures (e.g., touch, pharmacological
part (head) to 30 degree
skill and repositioning, nurse’s pain management
angle, practice calm
diversional presence), quite
activities (moving slowly
activities as environment and calm
when getting up on bed
indicated for activities.
and turning from side to
individual
side) and having
situations. 3.2 instruct in/encourage 3.2 to distract
adequate rest periods
use of relaxation attention and
such as taking a nap.
techniques such as focused reduce tension
breathing, imaging.

3.3 encourage having 3.3 to prevent

adequate rest periods. fatigue