The patient underwent an appendectomy and is experiencing acute pain at the surgical incision site, which they rate as a 5 out of 10 on the pain scale. The nursing diagnosis is acute pain related to the surgical incision. The goals are for the patient to report a reduction in pain to 3 out of 10 within 4 hours and to appear more relaxed. Nursing interventions include assessing and monitoring the patient's pain, keeping them on bed rest in a semi-Fowler's position, encouraging early ambulation, providing distraction, keeping the patient NPO and using NG suction initially, administering analgesics as needed, and applying an ice bag to the abdomen. The rationale for these interventions is to relieve pain, promote healing and
The patient underwent an appendectomy and is experiencing acute pain at the surgical incision site, which they rate as a 5 out of 10 on the pain scale. The nursing diagnosis is acute pain related to the surgical incision. The goals are for the patient to report a reduction in pain to 3 out of 10 within 4 hours and to appear more relaxed. Nursing interventions include assessing and monitoring the patient's pain, keeping them on bed rest in a semi-Fowler's position, encouraging early ambulation, providing distraction, keeping the patient NPO and using NG suction initially, administering analgesics as needed, and applying an ice bag to the abdomen. The rationale for these interventions is to relieve pain, promote healing and
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The patient underwent an appendectomy and is experiencing acute pain at the surgical incision site, which they rate as a 5 out of 10 on the pain scale. The nursing diagnosis is acute pain related to the surgical incision. The goals are for the patient to report a reduction in pain to 3 out of 10 within 4 hours and to appear more relaxed. Nursing interventions include assessing and monitoring the patient's pain, keeping them on bed rest in a semi-Fowler's position, encouraging early ambulation, providing distraction, keeping the patient NPO and using NG suction initially, administering analgesics as needed, and applying an ice bag to the abdomen. The rationale for these interventions is to relieve pain, promote healing and
Copyright:
Attribution Non-Commercial (BY-NC)
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Download as DOC, PDF, TXT or read online from Scribd
Cues Nursing Rationale Goals and Nursing Rationale Evaluation
Diagnosis Objectives Intervention Subjective: Acute pain Unpleasant After 4 hours Independent: After 4 hours “kumikirot-kirot related to sensory and of nursing Assess pain, Useful in monitoring of nursing yung bandang presence of experience intervention, noting effectiveness of intervention, inoperahan” as surgical arising from the patient location, medication, the patient verbalized by incision as actual or will be able to characteristics progression of was able to the patient. manifested potential tissue verbalize , severity (0- healing. Changes in verbalize pain by facial damage or relief of pain 10). characteristics of is reduced Objective: grimace described in or at least Investigate pain may indicate from pain Observed and report terms of pain is and report developing abscess/ scale 5/10 to evidence of of pain. damage; reduced from changes in peritonitis, requiring 3/10 and also pain; facial sudden or slow pain scale pain as prompt medical the patient grimace onset of any 5/10 to 3/10 appropriate. evaluation and was able to Verbalized intensity from and also the intervention appear pain at the mild to severe patient will relaxed. abdomen with an be able to Gravity localizes with a pain anticipated or appear Keep at rest in inflammatory scale of predictable end relaxed. semi-Fowler’s exudates into lower 5/10 and a duration position. abdomen or pelvis, Guarding of less than 6 relieving abdominal behaviour in moths. tension, which is the incision accentuated by site. Reference: supine position. Positioning page 498 to avoid pain Nurse’s Pocket Encourage Promotes Guide early normalization of Diagnoses, ambulation. organ function. prioritized interventions Provide Refocuses attention, and rationale diversional promotes relaxation, 11th edition by activities. and may enhance Doenges, coping abilities. Moorhouse and Murr Collaborative: Keep NPO/ Decreases maintain NG discomfort of early suction intestinal peristalsis initially. and gastric irritation/vomiting.
Administer Relief of pain
analgesics as facilitates indicated. cooperation with other therapeutic Place ice bag interventions. on the abdomen Soothes and relieve periodically, pain through during initial desensitization of 24-48 hours nerve endings. Note: as do not use heat appropriate. because it may cause tissue congestion/ increase edema formation. Reference: Page 354 Nursing Care Plan Guidelines for individualizing client care across the life span Edition 7 by Doenges, Moorhouse and Murr