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DIAGNOSIS Acute pain may be related to distention of intestinal tissue by inflammation and presence of surgical incision.
PLANNING Short term: After 1 hour of nursing interventions, the Patient will report pain is relieved or controlled and appear to be relaxed, able to sleep and rest appropriately.
INTERVENTION Independent Assess pain, noting locations, characteristics, and severity (0 to 10 scale). Investigate and report changes in pain, as appropriate.
RATIONALE Useful in monitoring effectiveness of medication and progression of healing. Changes in characteristics of pain may indicate developing abscess or peritonitis, requiring prompt medical evaluation and intervention. Being informed about the progress of situation provides emotional support, helping to decrease anxiety. Gravity localizes inflammatory exudate into lower abdominal or pelvis, relieving abdominal tension, which is accentuated by supine position.
EVALUATION Goal met After 1 hour of nursing interventions, the Patient was able to report pain is relieved or controlled and appear to be relaxed, able to sleep and rest appropriately.
OBJECTIVE: Guarding behavior in the abdomen Facial mask of pain Distraction behaviors
Promotes normalization of organ function; stimulates peristalsis and passing of flatus, reducing abdominal discomfort. Refocuses attention, promotes relaxation, and may enhance coping abilities. Relief of pain facilitates cooperation with other therapeutic intervention such as ambulation and pulmonary toilet. Soothes and relieves pain through desensitization of nerve endings. Goal not met. Due to lack of resources and time of the student nurse. To monitor the plan of care of the patient until the discharge.
Long Term: The patient will rate pain as less than or equal to 3/10 through discharge