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Assessment Diagnosis Planning Intervention Rationale Evaluation

The patient reported pain from their abdominal surgery. The diagnosis was acute pain from intestinal inflammation and the surgical incision. The short term plan was to relieve the patient's pain within 1 hour through nursing interventions so they could rest and sleep. The long term goal was for the patient to rate their pain as less than or equal to 3/10 by discharge.

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Romeo Avecilla Cabral
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567 views2 pages

Assessment Diagnosis Planning Intervention Rationale Evaluation

The patient reported pain from their abdominal surgery. The diagnosis was acute pain from intestinal inflammation and the surgical incision. The short term plan was to relieve the patient's pain within 1 hour through nursing interventions so they could rest and sleep. The long term goal was for the patient to rate their pain as less than or equal to 3/10 by discharge.

Uploaded by

Romeo Avecilla Cabral
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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ASSESSMENT SUBJECTIVE: Sumasakit and sugat ng opera ko) as verbalized by the patient.

DIAGNOSIS Acute pain may be related to distention of intestinal tissue by inflammation and presence of surgical incision.

PLANNING Short term: After 1 hour of nursing interventions, the Patient will report pain is relieved or controlled and appear to be relaxed, able to sleep and rest appropriately.

INTERVENTION Independent Assess pain, noting locations, characteristics, and severity (0 to 10 scale). Investigate and report changes in pain, as appropriate.

RATIONALE Useful in monitoring effectiveness of medication and progression of healing. Changes in characteristics of pain may indicate developing abscess or peritonitis, requiring prompt medical evaluation and intervention. Being informed about the progress of situation provides emotional support, helping to decrease anxiety. Gravity localizes inflammatory exudate into lower abdominal or pelvis, relieving abdominal tension, which is accentuated by supine position.

EVALUATION Goal met After 1 hour of nursing interventions, the Patient was able to report pain is relieved or controlled and appear to be relaxed, able to sleep and rest appropriately.

OBJECTIVE: Guarding behavior in the abdomen Facial mask of pain Distraction behaviors

Provide accurate, honest information to patient or significant others.

Keep at rest in semi-fowlers position.

Encourage early ambulation.

Provide diversional activities.

Promotes normalization of organ function; stimulates peristalsis and passing of flatus, reducing abdominal discomfort. Refocuses attention, promotes relaxation, and may enhance coping abilities. Relief of pain facilitates cooperation with other therapeutic intervention such as ambulation and pulmonary toilet. Soothes and relieves pain through desensitization of nerve endings. Goal not met. Due to lack of resources and time of the student nurse. To monitor the plan of care of the patient until the discharge.

Long Term: The patient will rate pain as less than or equal to 3/10 through discharge

Administer analgesics as indicated.

Place ice bag on abdomen periodically during initial 24 to 48 hours as appropriate.

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