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CUES EXPLANATI NURSING NURSING INTERVENTIONS RATIONALE EVALUATION

ON OF THE OBJECTIVES OF THE


PROBLEM CRITERIA
SUBJECTIVE DATA: Complex STO: DIAGNOSTIC: FULLY MET IF:
Ang sakit ng tahi responses After 3 hours of - Assess characteristic of pain. - Provides information to aid in Client will be free
ko, hindi ako of tissue and nursing interventions, determining choice or from pain.
makagalawa ng nerve endings the clients pain will effectiveness of interventions.
maayos. due to trauma be relieved as
from evidenced by rating
- Monitor vital signs - Knowledge of vital signs allows
surgery(incisio the pain from 3/10.
the therapist to understand a
OBJECTIVE DATA: n) and cause
patient's physiologic status and is
Pain rated as 8/10 hypersensitivit
Grimacing y to the LTO: helpful in determining appropriate PARTIALLY MET IF:
On guarding central After 73 hours of goals. Client will still rate
position during the nervous nursing interventions, the pain from more
interview system that the client will be able - Assess causes of possible - Discomfort can be caused or than 5/ 10.
Vital signs: BP: causes to be free of pain. discomfort other than operative aggravated by presence of non-
140/90 mmHg; PR: unpleasant procedure. patent indwelling catheters, NGT,
75bpm; RR: 25cpm; physical and parenteral lines (bladder pain,
Temp: 36.6C emotional gastric fluid and gas
reactions and accumulation, and infiltration of
responses IV fluids or medications).

THERAPEUTIC: NOT MET IF:


- INDEPENDENT - May relieve pain and enhance Clients pain will be
worsened.
- Reposition as indicated: semi- circulation. Semi-Fowlers
Fowlers position relieves abdominal
NURSING DIAGNOSIS: muscle tension and arthritic back
Acute Pain muscle tension
related to post-
op surgical - Improves circulation, reduces
incision muscle tension and anxiety
secondary to - Provide additional comfort associated with pain. Enhances
cholecystectomy measures: backrub, heat or cold sense of well-being.
applications.
- For relaxation, avoiding too
much pain.
- Divert attention to a pleasant
thing.
- Analgesics given IV reach the pain
centers immediately, providing
more effective relief with small
- COLLABORATIVE doses of medication.
- Administer Analgesics IV as
prescribed by the physician.
- To prevent bleeding of the
surgical incision made from the
operation.
EDUCATIVE:
- Instruct the client to avoid - To promote blood circulation and
strenuous exercise and faster healing of the incision.
activities.

- To aid in strengthening of having


- Instruct the client to have a a good immune system against
infection.
short walk everyday as a form
of exercise.
- Relieves muscle and emotional
tension; enhances sense of
- Advise the client to eat plenty control and may improve coping
of nutritious foods and abilities.
vegetables and drink plenty
of water.

- Encourage use of relaxation


techniques: deep-breathing
exercises, guided imagery,
visualization, music.

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