Medjo masakit ang sugat ko as stated by the client. The client graded the pain 4 out of 10 from the pain scale of 1-10 in which 10 is the worst possible pain.
OBJECTIVE DATA:
with blood pressure of 150/90
with facial mask of pain (grimace)
with guarding behavior
narrowed
Acute pain related to damaged physical integrity secondary to surgical incision as evidence by account of pain from the client
SHORT TERM: After 4 hours of nursing intervention the client will manifest diminish level of pain as evidence by pain scale of 4 out of 10 to 1 out of 10, decrement of blood pressure and absence of facial grimace.
INDEPENDENT INTERVENTIONS
1. Assess pain characteristics
2. Observe or monitor signs and symptoms associated with pain such as blood pressure, heart rate, temperature, and ability to focus
3. Distinguish the cause of pain
1. Assessment of the pain assists in planning management strategies.
2. Monitoring of associated signs may help in evaluating pain and measuring its degree.
3. Identifying the cause of pain aids in choosing the type of intervention that is to be
After 4 hours of nursing intervention the clients level of pain was reduced as evidence by decrease level of blood pressure from 150/90 to 130/90, absence of facial grimace and clients report of diminished level of pain from 4 out of 10 to 1 out of 10.
Goal was met. Date: September 21, 2012 Case: Post-op Exploratory Laparotomy
focus as demonstrate d by withdrawal from social contact
4. Identify the factors that may contribute to occurrence of pain
5. Eliminate additional stressors or sources of discomfort.
6. Provide rest period to facilitate comfort and carried out to the client.
4. Appraisal to the factors that contributes to occurrence of pain may help to eliminate the cause.
5. In the presence of stressors and sources of discomfort the clients threshold of pain decreases, elimination of these factors may help in increasing the ability of client to cope with pain.
6. Absence of rest during periods of pain may Date: September 21, 2012 Case: Post-op Exploratory Laparotomy
relaxation.
DEPENDENT INTERVENTIONS
1. Administer analgesic as prescribed
aggravate the level of pain.
1. An analgesic inhibits the prostaglandin synthesis, an agent that causes pain thereby producing anti- inflammatory effect and relieving the pain.