DIAGNOSIS

ANALYSIS

GOALS AND OBJECTIVES After 8 hours of nursing intervention the client will be able to manage pain from the scale of 8/10 to 4/10. -After 10 minutes of discussion, the client will be able to know how to manage pain.

NURSING INTERVENTION

RATIONALE

EVALUATION

Acute Pain r/t injuring agent secondary to cellulitis as evidenced by: Subjective: > Pain scale: 8/10 pag inaalis yung natuyo nabalat dun sasugat ko > Ang sakit ng paa ko pag ginagalaw ko. Objective: >guarding behaviour > pain on left lower extremity >grimace

Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months. ( Nanda 12th edition pp.586) When experiencing pain, people express pain through many different behaviors; Nonverbal or Behavioral expressions; A patient may grimace, cry, rub the affected area, guard

- Discuss proper positioning that could help relieve pain. Instruct to position at a semi-fowlers position.

-This position reduces the tension on the incision and abdominal organs, helping reduce pain.

Was the client able to know how to manage pain. Yes__ No__ Why?

- After 10 minutes of discussion, the client will be able to know how to tolerate pain.

-Dicuss the use of preffered and selected nonpharmacological techniques such as relaxation,

-To distract attention and reduce tension.

Was the client able to know how to tolerate pain. Yes__ No__ Why?

the affected area, guard the affected area or immobilize it. Ref.: Brunner and Suddarths Textbook of Medical-Surgical Nursing (12th Edition; Vol. I) p. 238

distraction or music therapy.

- After 10 minutes of discussion, the client will be able to know the advantages and effects of medications as needed.

-Discuss action, side effects, dosage and frequency of administration of prescribed analgesics.

-For clients knowledge.

Was the client able to know the advantages and the effects of medications? Yes__ No__ Why?

- After 10 minutes of discussion, the client will be able to know that treatment may cause pain.

-Discuss the advantages of frequent wound dressing changes that causes pain.

-To reduce anxiety.

Was the client able to know that treatment may cause pain? Yes__ No__ Why?

- After 10

-Discuss the

-To avoid

Was the client

minutes of discussion, the client will be able to know the importance of avoiding strenuous activities. After 20 minutes of administration the client will be feel relief of pain.

importance on how to limit activities. Instruct patient to avoid doing strenous activities.

occurrence of pain at the area.

able to know the importance of avoiding strenuous activities? Yes__ No__ Why?

- Administer the drugs such as analgesics as prescribed.

-Analgesics inhibits prostaglandin synthesis process in body tissue by inhibiting cyclooxygenase enzymes, therefore causes pain relief.

Was the client able to feel relief after few minutes of drug administration? Yes__ No__ Why?

Nursing Care Plan

Patients Name: H.P ADMITTING DX: Cellulitis @ L foot T2DM Prepared by: Aguirre, Kevin Sam D. BSN- 406