NSG.PROBLEM ANALYSIS GOAL/ NSG.

INTERVENTION RATIONALE EVALUATION

CUES OBJECTIVE/S
Unpleasant
Acute pain sensory and Goal:
related to post emotional
partum experience After 8 hours of
physiologic arising from nursing
changes actual or intervention
potential with in the shift,
tissue the patient
S> “ mahapdi damage or report pain is
nga yug tahi ko described in relieved/controll
eh “ terms of ed as a result of
such ongoing
>Pain scale 6 damage assessment &
(ten is the (internationa early
highest) l association interention.
for the study Independent
O> (+) Facial of pain);
grimace sudden or Objectives:
slow onset
>Guarding of any Within 8 hours
behavior. intensity of shift, the
from mild to client will be
> positioning to severe with able to: Assess intensity, May be mild to severe 1.) Had
avoid pain. an description, and with radiation to carefully
anticipated location/ radiation of shoulders/ occipital assessed
>restless or pain, changes in area (cervical) or the
predictable sensation. hips/buttocks intensity
>Reduced end and 1.) Be (lumbar), description
interaction with duration of carefully Numbness/tingling of the pain.
people in less than 6 assess the discomfort may reflect
environment months intensity return of sensation
descriptio after nerve root
n of the decompression or
pain. result from developing
edema of compressed
nerve/operative site.
Review expected
manifestation/change Development/resolutio 2.) Had
s in intensity of pain. n of edema and carefully
inflammation in the assessed
immediate post changes in
operative phase can intensity of
affect pressure on pain.
2.) Be various nerves and
carefully cause changes in
assess degree of pain
changes (especially 3 days
in after operation, when
intensity Allow patient to muscle spasms/
of pain assume position of improved nerve root
comfort if indicated. sensation intensity
Use logrolls for pain). 3.) Had
position changes. displayed
relaxed
posture &
Positioning is dictated, be able to
by physical rest
3.) Be preference, type of appropriatel
 carefully operation (e.g., head y.
provide of bed may be slightly
comfort elevated after cervical
by proper laminectomy) Re
positionin adjustment of position
g Provide back rub/ aids in relieving
massage avoiding muscle fatigue and
operative site. discomfort. Logrolling
avoids tension in the
operative areas and
maintains straight
spinal alignment. 4.) Had
carefully
provided
4.) Be Demonstrate/encoura Relieves/reduces pain comfort by
carefully ge use of relaxation by alteration of providing
provide skills, e.g., deep sensory neurons, massage.
comfort breathing exercise. muscle relaxation.
by
providing Collaborative 5.) Had
massage. carefully
Administer encouraged
analgesics, as relaxation
5.) Be carefully indicated: Refocuses attention, skills
encourage reduces muscle
relaxation skills tension, promotes
sense of well-being,
and
controls/decreases
discomfort.
Given for pain
relief/control