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  • Cues Nursing Diagnosis Objective Intervention Rationale Evaluation

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    Olive Keithy Ascaño Reyes
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    A 32-year-old male patient named A.D. underwent an appendectomy performed by Dr. Tobongbanua. He reported a pain level of 5/10 after the surgery. The nursing diagnosis was acute pain related to the surgical incision. The objectives were to reduce the patient's pain level to 3/10 and have him verbalize relief and feel relaxed. Interventions included pain assessment, rest, early ambulation, diversional activities, and analgesics. After 4 hours, the patient reported his pain was reduced to 4/10 and he appeared relaxed, partially meeting the goals.

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    NCP IN OPERATING ROOM

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    ncp.docx

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    A 32-year-old male patient named A.D. underwent an appendectomy performed by Dr. Tobongbanua. He reported a pain level of 5/10 after the surgery. The nursing diagnosis was acute pain related to the surgical incision. The objectives were to reduce the patient's pain level to 3/10 and have him verbalize relief and feel relaxed. Interventions included pain assessment, rest, early ambulation, diversional activities, and analgesics. After 4 hours, the patient reported his pain was reduced to 4/10 and he appeared relaxed, partially meeting the goals.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
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    Download as docx, pdf, or txt
    54 views1 page

    Cues Nursing Diagnosis Objective Intervention Rationale Evaluation

    Uploaded by

    Olive Keithy Ascaño Reyes
    A 32-year-old male patient named A.D. underwent an appendectomy performed by Dr. Tobongbanua. He reported a pain level of 5/10 after the surgery. The nursing diagnosis was acute pain related to the surgical incision. The objectives were to reduce the patient's pain level to 3/10 and have him verbalize relief and feel relaxed. Interventions included pain assessment, rest, early ambulation, diversional activities, and analgesics. After 4 hours, the patient reported his pain was reduced to 4/10 and he appeared relaxed, partially meeting the goals.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 1

    NAME: A.D AGE : 32 y.

    SURGEON: DR. TOBONGBANUA DIAGNOSIS: APPENDECTOMY

    CUES
    Subjective Data: Masakit do operasyon as verbalized by the patient after operation. (appendectomy) Pain scale 5/10 Objective Data: The patient manifested:

    NURSING DIAGNOSIS
    Acute pain related surgical incision as manifested by facial grimace and report of pain

    OBJECTIVE
    General: Pain scale will be reduced from 5/10 to 3/10 Specific: Patient will be able to verbalize relief of pain Patient will be able to feel relaxed

    INTERVENTION
    Independent: Assess pain, noting location, characteristics, severity (0-10). Investigate and report changes in pain as appropriate. Keep at rest in semiFowlers position. Encourage early ambulation. Provide diversional activities. Collaborative: Keep NPO/ maintain NG suction initially. Administer analgesics as indicated. Place ice bag on the abdomen periodically, during initial 24-48 hours as appropriate.

    RATIONALE
    Useful in monitoring effectiveness of medication,progression of healing. Changes in characteristics of pain may indicate developing abscess/peritonitis,requiring prompt medical evaluation and intervention. Gravity localizes inflammatory exudates into lower abdomen or pelvis, relieving abdominal tension, which is accentuated by supine position. Decreases discomfort of early intestinal peristalsis and gastric irritation/vomiting. Relief of pain facilitates cooperation with other therapeutic interventions. Soothes and relieve pain through desensitization of nerve endings.

    EVALUATION
    Goals partially met. After 4 hours of nursing intervention, the patient was able to verbalize pain is reduced from pain scale 5/10 to 4/10 and also the patient was able to appear relaxed.

    Facial Grimace Abdominal guarding Sweating

    V/s taken: CR 44 bpm O2 Sat- 99% BP 88/49 mmHg

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