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Roxanne M.

Navarro NPD2 ASSESSMENT S: > masakit yung inooperahan sakin as verbalized by the patient >complained of deep sharp pain on left neck whenever moving, rated as 8/10 on painscale. EXPLANATION OF THE PROBLEM Complexresponses of tissue andnerve endingsdue to traumafrom surgery(incision) andcausehypersensitivity to thecentralnervoussystem thatcausesunpleasantphysical andemotionalreactions andresponses OBJECTIVE STO:

Nursing Care Plan

Feb. 13, 2014 C.I: Jesus P. Aniban RN MAN RATIONALE EVALUATION STO: Indicative of pain Within 8 hours of nursing interventions,the patient was able to: >report relief from pain

INTERVENTIONS DX: Monitor and record vital signs

Within 8 hours of nursing interventions, the patient will be able to: >report relief from pain >report pain is reduced to 4/10

Assess the clients perception, level of understanding and needs

to identify and assess the nursing interventions to be done

LTO: O: >grimaces >guarding or protective behavior on the incision site >positioning to avoid pain >can perform ADLs with minimal Within 3 days of nursing interventions, the patient will be able to: > report pain is controlled >report that pain decreased from 8/10 to 2/10

>report pain is pain is a subjective reduced to 4/10 Assess the severity, frequency, data, therefore it and characteristic of pain and should be encourage the patient to reported and to verbalize report during and determine after each nursing patients level of LTO: intervention pain Within 3 days of nursing interventions, the TX: to support the abdominal muscle patient was able to: Advise the use of pillow when moving. support to abdominal area > report pain is when moving, coughing or controlled ambulating by hugging the >report that pain pillow tight on the abdominal decreased from 8/10 area. to 2/10

Roxanne M. Navarro NPD2 assisstance

Nursing Care Plan

Feb. 13, 2014 C.I: Jesus P. Aniban RN MAN to divert the attention.

provide divertional activities such as reading newspapers Nursing Diagnosis: Acute pain related to surgical incision Provide comfort measures like touch, repositioning

to provide non pharmacologic pain managemen

Encourage use of relaxation techniques such as focused breathing

To distract attention and reduce tension

Administer medication as ordered

to minimize the pain

Edx: encourage early ambulation

to promote blood circulation

Roxanne M. Navarro NPD2

Nursing Care Plan

Feb. 13, 2014 C.I: Jesus P. Aniban RN MAN

instruct the client to avoid strenuous activities and exercises

to prevent bleeding on the surgical incision

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