CUES Nursing Background Knowledge

(defining Diagnosis (pathophysiologic/psychosocial Goals and Nursing Rationale Evaluation

characteristics Problem & Explanation/consequences of Objectives Interventions
of Nrsg Dx) Etiology Nrsg. Dx)
S/Sx)
Subjective:
“Masakit yung Acute pain Pain Stimulus→visceral and After 2 hours >Provide >To alleviate After 2 hours
tahi ko lalo na related to Cutaneous of Nursing Comfort pain by of Nursing
kapag surgical Fibers:Nociceptor(skin and Interventions Measures such promoting non- Interventions
gumagalaw incision due internal organ)→Dorsal the patient’s as repositioning pharmacological the patient’s
ako” to cesarean Horn→reticular pain scale will or quiet pain pain scale
birth as Formation(sleep decrease from environment management decreased
Objective: evidenced center)→Thalumus→Limbic 4 to 2 from 4 to 2
>Facial by facial Cortex→Cerebral >Instruct the >To distract
Grimace with grimace Cortex→Perception of patient to use attention and
pain scale of 4 with a pain Noxious stimuli relaxation reduce tension Goal is met
>Protective scale of 4 techniques and
Gesture to The harmful effects of encourage
avoid pain in unrelieved acute pain can diversional
incision site affect the pulmonary, activity such as
>Expressive carrdiovascular,GIT,Endocrine listening to
Behavior such system and can cause severe music,watching
as sighing pain and it may increase the television and
>Limited risk of developing physiologic socialization
movement disorders. with others

>Instruct >To reduce pain

patient to us especially when
supportive moving
materials such
as binder

>Encourage >It promotes

patient to do healing of
Deep Breathing surgical wounds
Exercise by
demonstrating
how to do
it(every 4 hour
daily with 5-10
breaths during
exercise