Assessment

Diagnosis

Planning

Intervention Rationale Evaluation

Subjective:“masakit po yung tahi ko pag gumagalaw”As verbalized by the client

Objective:Facial grimace;Temp 37.3;Guarding behavior;Pain while talking;Pain scale of 7/10;PR:120

Pain related to surgical procedure as evidenced by facial grimace and guarding behavior.

After8 hours of nursing intervention client’s pain scale of 7/10 will decrease to 4/10

Independent:-Keep at rest in semi-Fowler’s position.

- Encourage early ambulation.

- Provide diversional activities.

- Place ice bag on abdomen periodically during initial 24–48 hr, as appropriate.

Dependent:Administer analgesics as indicated.

- Gravity localizes inflammatory exudate into lower abdomen or pelvis, relieving abdominal tension, which is accentuated by supine position.

- Promotes normalization of organ function, e.g., stimulates peristalsis and passing of flatus, reducing abdominal discomfort.

- Refocuses attention, promotes relaxation, and may enhance coping abilities.

- Soothes and relieves pain through desensitization of nerve endings. Note: Do not use heat, because it may cause tissue congestion

Relief of pain facilitates cooperation with other therapeutic interventions, e.g., ambulation

After 8 hours of nursing intervention client’s pain scale is reduced to 4/10 from 7/10

Post appendectomy NCP