Cues Subjective: (intubated) Objective: Facial grimace Irritable Guarding behavior Pain assessment Location: Left suboccipital area

area and neck Precipitating factors: upon movement Time: Frequent

Diagnosis Acute pain related to tissue trauma secondary to surgical incision as manifested by the signs and symptoms.

Inference Stimuli (surgical incision) tissue trauma Nerve Fibers (nociceptors) A-delta fiber C-fiber myelinated unmyelinated (fast) (slow) Dorsal horn of the spinal cord (primary touch fiber) NeospinoPaleospinothalamic thalamic tract (sharp, tract (dull, bright pain) aching pain) Substantia Gelatinosa (synapse) Thalamus (center of awareness of pain) Cerebral Cortex (center of interpretation) Acute Pain Responses (Facial grimace, Irritability, Guarding Behavior)

Plan of care

Nursing Interventions After 2 hours of Independent nursing Monitored interventions, vital signs the patient will Performed a verbalize comprehensive minimized pain assessment of as evidenced pain which by: includes its Patien location, t shows characteristics, incision duration, pain is intensity and controlled frequency, and precipitating tolerable. and relieving Patien factors. t manifests Ascertained that pain possible incidence psychological can be felt and emotional infrequently factors that & slightly. contribute to Facial pain including grimace will fear, anxiety disappear. and grief. Irritability Encouraged & guarding verbalization behavior of feelings recedes. about the pain. Informed client about pain relief measures, including how long it takes to achieve relief

Rationale Provide baseline data. To assess etiology/ causative factors so as to provide effective and efficient treatment.

Evaluation Goal Met: After 2 hours of nursing interventions, the patient verbalized minimized pain as evidenced by: Patient showed incision pain is controlled and tolerable. Patient manifested that pain incidence can be felt infrequently & slightly. Facial grimace disappeared. Irritability & guarding behavior receded.

Personal factors can induce pain.

Enhances trust and therapeutic relationship. Pain is exacerbated by the anxiety of unknown. Providing information promotes

and how long to expect relief to last.

Assisted client with slow, controlled deep breathing.

Encouraged diversional activities such as socialization and imagery. Provided a quiet and comfortable environment.

Offered comfort measures such as back rubs and massages. Encouraged the patient to take adequate

relaxation, reduces fears, and enhances therapeutic effectiveness of the drug. Deep breathing promotes relaxation and reduces muscle tension and also enhances lung expansion. To redirect the clients attention and to minimize pain and anxiety. Sustain a stress-free feeling to the patient and promotes effective coping to manage discomfort. Back massage aids in muscle relaxation. Pressure helps to counteract some of the pain. To decrease fatigue and conserve

sleep. Depenedent Administered ketorolac as prescribed by physician.

energy. NSAIDs have an analgesic and anti inflammatory effect.

Cues Subjective (intubated) Objective Limited range of motion Decreased muscle strength and control Inability to move purposefull Reluctance to attempt movement

Diagnosis Impaired physical mobility related to neuromuscular impairment secondary to postoperative incision as manifested by limited range of motion, decreased muscle strength and control and inability to move purposefully and reluctance to attempt movement.

Inference Suboccipital Craniectomy Muscle are Small blood disrupted vessels of and Decreased surrounding neuromuscular tissues are transmission torn of nerve impulses Hemorrh age Hemato ma Swelling Pain and tenderness Impaired Physical Mobility

Plan of care After 8 hours of nursing interventions, the patient will maintain mobility at the highest possible level as evidenced by: Increa ses strength and function on affected and compensato ry parts. Patien t demonstrate s techniques that enable resumption of activities. Patient demonstrate s use of relaxation skills & diversional activities as indicated for his situation. Patient shows

Nursing Rationale Interventions Independent Monitored vital Provide signs baseline data. Assessed degree Patient may be of immobility restricted by produced by self-view/selfinjury and note perception out patients of proportion perception of with actual immobility. physical limitations, requiring information and interventions to promote progress toward Encouraged wellness. verbalization of feelings. Enhances trust and therapeutic Provide means relationship. to summon help. Enables patient to have sense of control, and reduces fear of being left alone. Encouraged participation in Provides diversional and opportunity for recreational release of activities. energy, refocuses attention, enhances patients sense of self- control and self-worth,

Evaluation Goal met: After 8hours of nursing interventions, the patient was able to maintain mobility at the highest possible level as evidenced by: Increa sed strength and function on affected and compensato ry parts. Patien t demonstrate d techniques that enable resumption of activities. Patient demonstrate d use of relaxation skills & diversional activities as indicated for his situation. Patient showed

decrease reluctance to attempt movement

and aids in reducing social isolation. This is to prevent diminished circulatory & Provided a quiet nerve function and comfortable & control environment. swelling of the site. Sustain a stress Encouraged free feeling to client to assume the patient and different promotes positions and effective change them coping. regularly. Position Encouraged changes coughing and promote deep breathing comfort, reduce exercises. muscle tension Encouraged the and relieve patient to take pressure. adequate sleep. Advised to elevate and support injured extremity. Prevents respiratory complications. To decrease fatigue and conserve energy. This promotes healing by reducing basal metabolic rate & allowing

decrease reluctance to attempt movement

Provided reinforcement for positive coping mechanisms.

oxygen & nutrients to be utilized for tissue growth, healing & regeneration. Positive reinforcements enhance selfesteem and control.