RUEL ESPELLARDO 35/M Assessment Diagnosis Inference Planning Intervention Rationale Evaluation

Subjective:

Discomfort related to

Surgical Procedure

After 8 hours Established of nursing intervention rapport

building up trust helps Nursepatient interaction

After 8 hours of nursing intervention, Goal met as evidence by: Expression of reduction

"Medyo masakit po yung butas sa tiyan ko"

acute pain as manifested by Release of chemical mediators

the patient will

as verbalized verbalization (Substance P, by the patient of pain, facial grimace and Objective: (+) facial grimace; with a pain scale of 4/10 (+) guarding behaviour RR: 33bpm Discomfort guarding behaviour. Pain Inflammation

-Express

more effective Assisted patient to position affects the patient's ability to sleep

prostaglandins) reduction of discomfort

of discomfort (-) facial grimace Appearance

-Appear

find position

relaxed, able of comfort to rest appropriately

effectively. of being Encouraged early ambulation it enhances coping abilities. Administer prescribed pain medication provides relief of discomfort and keeps the comfort relaxed

level of the patient.