Acute pain r/t postoperative procedure ASSESSMENT SUBJECTIVE: Masakit kapag lumulunok ako DIAGNOSIS Acute r/t stimulation

of OBJECTIVE: Patient manifested : Pain neck on the during nerve endings secondary to surgical procedure . pain SCIENTIFIC EXPLANATION Depending on the depth nerve ,either exposed in pain of injury endings become ,resulting and until leaving ,with for of sense, LONG TERM: After days nursing intervention the patient 2 of SHORT TERM: After hours nursing intervention the patient will verbalize relief tolerable level. of Note reports of pain, including duration, location, intensity Pain but if is not always present, present be with pain LONG TERM: After 2 days of The shall verbalized nursing patient intervention should compared patients previous symptoms. This comparison may assist diagnosis in of pain within 6 of Monitor vital signs To to note have any baseline data & changes in vital signs. Independent Assess condition. patients To have baseline data SHORT TERM: After 6 hours of The shall verbalized relief of pain within tolerable level. nursing patient intervention PLANNING INTERVENTION RATIONALE EVALUATION

discomfort damaged insensate potential permanent impairment ability touch and pain. to

wound closure are the innervated area

swallowing because of post thyroidectomy . Pain 7/10 . V/S take and as Recorded follows: T-36.6 C P-68bpm R-16cpm BP-100/60 mmHG scale of

(010 scale)

,pressure

will Patient may manifest: Abdominal guarding Restlessness Facial grimacing verbalize relief tolerable level. . Review factors that aggravate alleviate pain. or of pain within

etiology bleeding

of and

relief of pain within tolerable level. .

development of complications. Helpful establishing diagnosis treatment needs. and in

Encourage patient to assume position of comfort.

Reduces abdominal tension of control. and promotes sense

Provide implement prescribed modifications.

and dietary

Patient receive initially. oral allowed, choices

may nothing When is food depend

by mouth (NPO) intake

on the diagnosis May be narcotic Administer medications indicated: e.g., morphine sulfate as of choice to relieve pain and reduce peristaltic activity. Meperidine (Demerol) with has been associated increased of incidence Note:

Analgesics, acute/severe

nausea/vomiting

Risk for Infection related to inadequate primary defenses due to tissue trauma caused by surgery. ASSESSMENT S>O O> Patient manifested : V/S take and as Recorded follows: T-36.6 C P-68bpm R-16cpm BP-100/60 mmHG Patient may Manifest: Increased environmental exposure ,tissue destruction. Inadequate primary defenses, due to abdominal Long-Term: After 1 day of nursing intervention the client will be able to demonstrate techniques to Position client properly to reduce intrabdominal pressure Positioning the client properly will help alleviate pain DIAGNOSIS Risk for infection related to inadequate primary defenses due to tissue trauma caused by surgery. SCIENTIFIC EXPLANATION A surgical incision is prone to pathogenic bacteria that will cause infection to the broken skin.The bacteria will be able to enter the incision and may infect the wound. Short- Term After 2 hours of nursing intervention the client will be able to identify interventions to prevent the risk for infection like hand washing. Assess for pain To determine the level of discomfort of the client Provocation, quality, radiation, severity, time of occurrence Long-Term: After 1 day of nursing intervention the client shall be able to demonstrate techniques to Assess vital signs(PR,RR and temperature ) To determine baseline data ,fever ,maybe secondary to infection. Short- Term After 2 hours of nursing intervention the client shall be able to identify interventions to prevent the risk for infection like hand washing. PLANNING INTERVENTION RATIONALE EVALUATION

incision and trauma brought about by surgery . (+) pain

decrease risk for infection such as frequent changing of dressing. Provide client with a distraction such as an activity or by watching television or talking to the client. Assess the surgical incision for signs of infection. Stress proper hand washing when the patient is going to have in contact to the wound. To prevent Change Dressing as ordered. infection. To prevent cross contamination. To know presence of infection. A distraction may help client deviate her attention from the pain.

decrease risk for infection such as frequent changing of dressing.

For Administer antibiotics as ordered. To Dependent: Administer meds as Ordered prevent further discomfort and aggravation of the injured site. or to relieve pain . prophylaxis.

1. Acute pain r/t postoperative procedure S>Masakit lalamunan ko kapag lumulunok ako as verbalized by the patient.

O> Received patient on bed in supine position, conscious and coherent with ongoing IVF D5NM 1L X 30gtts/min, Infusing well on left metacarpal vein. The patient appears weak, restlessness, irritable with initial vital signs of: T: 36.6 C P: 68 bpm, R: 16cpm and BP: 100/60 mmHg.

A> Acute pain r/t postoperative procedure P> After 4 hours of nursing interventions the patients pain will be reduce in a tolerable level from 7/10 to 4/10.

I>Established rapport to patient and SO >Assessed patients general condition >Monitored and record Vital Signs . >Assessed general condition on ability to swallow >Noted reports of pain, including location, duration, intensity (010 scale) > Reviewed factors that aggravate or alleviate pain. > Encourage to eat soft foods such as cake,mashed potato. > Encouraged small, frequent meals > Encourage patient to assume position of comfort. >Due meds given

E> Goal met aeb ;The patient verbalized relief of pain within a tolerable level from7/10 to 4/10 .