0 évaluation0% ont trouvé ce document utile (0 vote)
63 vues2 pages
The client reports pain after surgery that makes it difficult to move properly. On examination, the client rates the pain an 8/10, is grimacing, and guarding the surgical site. Vital signs are elevated. The nursing objectives are to relieve the client's pain to less than 3/10 in 3 hours and ensure the client is pain free after 72 hours with interventions like repositioning, back rubbing, heat/cold, and analgesics administered IV as prescribed. The nursing interventions are aimed at relieving pain, improving circulation, and preventing infection to aid recovery.
The client reports pain after surgery that makes it difficult to move properly. On examination, the client rates the pain an 8/10, is grimacing, and guarding the surgical site. Vital signs are elevated. The nursing objectives are to relieve the client's pain to less than 3/10 in 3 hours and ensure the client is pain free after 72 hours with interventions like repositioning, back rubbing, heat/cold, and analgesics administered IV as prescribed. The nursing interventions are aimed at relieving pain, improving circulation, and preventing infection to aid recovery.
The client reports pain after surgery that makes it difficult to move properly. On examination, the client rates the pain an 8/10, is grimacing, and guarding the surgical site. Vital signs are elevated. The nursing objectives are to relieve the client's pain to less than 3/10 in 3 hours and ensure the client is pain free after 72 hours with interventions like repositioning, back rubbing, heat/cold, and analgesics administered IV as prescribed. The nursing interventions are aimed at relieving pain, improving circulation, and preventing infection to aid recovery.
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.
Subjective Data: Objective Data: - Well Appearing But Independent Nursing Interventions: - Review Intraoperative Desired Outcome. Goal Met. Patient Was Able To