Assessment Subjective: Patient verbalized “masakit yung tahi dito sa tiyan ko. Mga 5 ang sakit niya pero kaya ko pang tiisin. Sumasakit lang siya pag may kinakain ako o kaya pag masyado akong gumagalaw.” Objective cues: Assessed pain scale, dressing is not soaked of bloody discharge, guarding behavior noted when patient moves, facial grimace noted

Nursing Diagnosis Pain related to abdominal surgical incision (on abdomen with a surgical incision of 4 inches) manifested by verbal report of pain & guarding behavior.

Rationale

Goal/Objective

Pain is one of the mos t complex human experiences, is an invisible phenomenon influenced by the interaction of emotion, behavioral, cognitive and physiologicsensory factors. Because pain is a highly individual experience, the basis for pain management is simply the client’s verbalization of pain. Fundamental of nursing, CRAVEN p 1168

Goal: After 8 hours of nursing intervention patient will report a decrease of pain from 5 to 4 and below. Objective: After 4 hrs. patient will be able to: - demonstrate different relaxation techniques to decrease pain - understand a need for rest period after each activity done.

Intervention Diagnostic Assess pain scale Monitor vital signs Therapeutic: -Provide a quiet environment - Assist patient during activities -ister analgesic if indicated Health Teaching: - Emphasize importance rest periods after every activity

Rationale

Evaluation

Goal: Helps to determine After 8 hours of effectiveness of therapy nursing intervention for pain patient verbalized To monitor if there are pain scale of 3 any changes Objective: After 4 hrs. patient To minimize stress that was able to: patient is experiencing - demonstrate To minimize feeling of different relaxation pain techniques to To provide relief decrease pain through drug - understand a need interaction for rest period after each activity done For client to understand that rest periods after each activity will relieve stress, muscle tension & increase relaxation

INTRA-OP Assessment Objective cues: Patient’s vital signs is closely monitored, patient is in a supine position, the abdomen is exposed

Nursing Diagnosis Risk for infection related to surgical procedure manifested by surgical instruments introduced in the body

Rationale

Goal/Objective

Any invasive device that enters the body provides a portal of entry for microorganisms, thus increasing the chance infection. Fundamental of nursing, Craven p 1039

Goal: After 8 hours of nursing intervention patient will not manifest signs and symptoms of infection during the whole procedure. Objective: After 4 hrs the patient will be able to recover from surgery without any complications. -will be able to understand importance of well-balanced diet.

Intervention Diagnostic Monitor vital signs Assess incision site Therapeutic: - Provide a clean environment - minimize touching the incision -ister antibiotics if indicated Health Teaching: -instruct patient & family importance of wellbalanced diet high in protein calories. -discuss sources of vitamin C & vitamin supplements

Rationale Helps to determine effectiveness of therapy for pain To monitor if there are any changes To minimize stress that patient is experiencing To minimize feeling of pain To provide relief through drug interaction Wound healing requires protein & calories for building new cells. The immune system depends on protein & calories to produce antibodies.

Evaluation Goal: After 8 hours of nursing intervention patient did not manifest signs and symptoms of infection during the whole procedure & after the procedure. Objective: After 4 hrs the patient was able to recover from surgery without any complications. -was able to understand importance of wellbalanced diet.