Assessment S- Masakit ang tahi ko. as verbalized by the patient.

Pain Scale: 7/10 O- V/s: BP- 120/80 mmHg T- 36.8 C RR- 20cpm PR- 100bpm - Afebrile - Increase pain due to surgical incision -Facial grimace - Body malaise - Good skin turgor - Redness

Nursing Diagnosis Acute pain related to the surgical incision as manifested by facial grimace, an increase of pain on the incision site. (Pain scale: 7/10)

Outcome Identification After 1hr the client will verbalized/re ported reduced or controlled of pain.

Planning 1. Establish rapport 2. Monitor and record V/S q2 3. Encourage the patient to verbalize feeling of pain 4. Encourage deep breathing exercise 5. Encourage the patient to use of relaxation techniques 6. Encourage adequate rest 7. Encourage early ambulation 8. Administer analgesics as order by the Physician

Intervention Independent 1. Established rapport 2. V/S monitored and recorded q2 3. Encouraged the patient to verbalized feeling of pain 4. Encouraged deep breathing exercised 5. Encouraged the patient used of relaxation techniques 6. Encouraged adequate rest 7. Encouraged early ambulation Dependent 8. Administered analgesics as ordered by the Physician

Rationale 1. To promote cooperation and compliance 2. Serves as baseline 3. To know if theres changes 4. To alleviate pain 5. To distract attention and reduce tension 6. To prevent fatigue 7. To promotes normalization of organ function

Evaluation
1. Met- Rapport

was established
2. Met- V/S

3.

4.

5.

6.

7.

8.

monitored and recorded q2 Met- Patient verbalized feeling of pain Met- Patient practiced deep breathing exercised Met- Patient used of relaxation activities like reading newspaper Met- Patient had enough adequate rest Met- Patient practiced early ambulation Unmet- Only the staff nurse led in giving medication

Assessment SO- V/S: BP110/80mmHg T-36.5C PR-81bpm RR-24cpm - Presence e of surgical incision - Broken skin - Soak dressing for 3days - Swelling

Nursing Diagnosis Risk for infection related to decrease primary defences as manifested by presence of surgical incision, soak dressing for 3 days, swelling and broken skin.

Outcome Identification After 1-2hrs of nursing intervention client will prevents occurrence of infection

Planning 1. Establish rapport 2. Monitor for V/S q2 3. Observe for localize sign of infection 4. Assess skin conditions 5. Practice aseptic technique 6. Change surgical wound dressing using proper technique for changing/dispo sing contaminated materials 7. Administer antibiotics as order by the Physician

Intervention Independent 1. Established rapport 2. V/S monitored q2 3. Observed for localized sign of infection 4. Assessed skin conditions 5. Practiced aseptic technique 6. Changed surgical wound dressing using proper technique for changing/dispo sing contaminated materials Dependent 7. Administer antibiotics as ordered by the Physician

Rationale 1. To promote cooperation and compliance 2. Serves as baseline data 3. To prevent risk/occurre nce of infection 4. To if theres any sign of infection 5. To develop germ-free environmen t to protect a patient from infection 6. To prevent occurrence of infection 7. To prevent the spread of bacteria

Evaluation 1. Met- Rapport was established 2. Met- V/S monitored q2 3. Met- Localized sign of infection was observed 4. Met- Skin condition was assessed 5. Met- Hand washing done and the sterility of materials was maintained 6. Met- Wound dressing was changed by the used of proper technique 7. Unmet- The staff nurse lid in giving medications