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Lurese Joy Basug

BSN 3-H

Patient’s Name: Acorda, Ariza Mhae


Assessment Diagnosis Planning Selected Rationale Implemented Evaluation
Intervention Intervention

Subjective: Acute Pain related After doing >Establish rapport > To reduce patient >Rapport
“Masakit parin to post-op surgical nursing anxiety and to be Established
kung san siya incision interventions, the able to be able to
inoperahan” As patient will be gain cooperation
verbalized by the able to report
mother. relieved pain >Monitor v/s > To obtain baseline >v/s monitored and
data, and for further recorded
Objective: comparison of
>Received patient results
awake on bed
>Conscious and > Observe non- >To assess if there is >non-verbal cues
coherent verbal cues of pain still pain observed
>Ongoing IVF#6
D5NM x17gtts/min; >Perform a >Pain is a >Performed
hooked at left comprehensive subjective comprehensive
metacarpal; assessment of pain experience assessment of pain
infusing well to include and must be
>afebrile – 36.8°C location, described by
>ambulatory characteristics, the client in
>(+) abd. Pain onset, order to plan
>Facial grimace duration, effective
>(-) sign of frequency, treatment.
infection at the quality,
incision site intensity
>on guarding or
position severity,
>abdominal and
incision, with precipitating factors
dressing dry and of pain
clean
>Pain scale of 2/10 >Give health >To broaden >Health teaching
teaching about pain patients knowledge done
management about pain

>Encourage to do >To lessen the pain >Deep breathing


deep breathing and to relax exercises done
exercise

>Encourage >To promote >Encouraged


adequate rest comfort and adequate rest
periods prevent fatigue periods

>Administer pain >To reduce pain


relievers as pharmacologically
prescribed by the
physician

>Monitor I & O >To evaluate >I & O monitored


accurate fluid status

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