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NCP

The patient reported a pain level of 6/10 at the surgical site. Vital signs were within normal limits. The nursing diagnosis was acute pain related to disruption of skin, tissue, and muscle integrity. Interventions included providing information about pain management, repositioning, encouraging adequate rest, diet, and fluids, administering prescribed analgesics to relieve pain, and using relaxation techniques. The outcome was to relieve or control the patient's pain within 8 hours, which was met.

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Chivaslaine Ganmor
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88 views2 pages

NCP

The patient reported a pain level of 6/10 at the surgical site. Vital signs were within normal limits. The nursing diagnosis was acute pain related to disruption of skin, tissue, and muscle integrity. Interventions included providing information about pain management, repositioning, encouraging adequate rest, diet, and fluids, administering prescribed analgesics to relieve pain, and using relaxation techniques. The outcome was to relieve or control the patient's pain within 8 hours, which was met.

Uploaded by

Chivaslaine Ganmor
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Assessment

Nursing Diagnosis

Outcome Identification

Intervention

Rationale

Evaluation

Subjective: Masakit yung tahi ko as verbalized by patient. Objective: Facial Grimace. Guarding behavior. Narrowed focus. Pain Scale ( 6/10) V/S taken as follows: T: 36.5 P: 63 R: 22 Bp: 130/90

Acute pain related to disruption of skin, tissue, and muscle integrity

After 8 hours of nursing interventions, the patient pain will be relieved or controlled.

Independent:

Provides information about need for or Evaluate pain regularly effectiveness of noting characteristics, interventions location, intensity (610 scale). Prevents undue strain on operative site. Identify specific activity limitations Promotes return of normal function and Recommend planned enhances feelings of or progressive general well being. exercise. Prevents fatigue and conserves energy for Schedule adequate rest healing. periods. Provides elements necessary for tissue Encourage to eat regeneration or nutritious diets and healing. adequate fluid intake. May relieve pain and enhance circulation. Reposition as indicated. Improves circulation,

Met

Met

Met

Met

Met

Met

Met

Provide additional comfort measures like back rub.

reduces muscle tension and anxiety associated with pain. Relieves muscle and emotional tension.

Met

Encourage use of relaxation technique like deep breathing exercises. Collaborative: Administer analgesics or non steroidal antiinflammatory drugs as prescribed.

Met To relieve mild or moderate pain.

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