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    Mark Anthony Ibay
    The patient reported pain from sutures as evidenced by a pain scale rating of 7 out of 10. Upon examination, the patient exhibited signs of pain including restlessness, irritability, cold clammy skin, excessive perspiration, facial grimacing, and increased respiration. The nurse's interventions included repositioning the patient, providing comfort measures, assisting with breathing techniques, ensuring a quiet environment, encouraging diversional activities, monitoring vital signs, and administering analgesics as ordered. The goal was to reduce the patient's pain to a level of 3 or less within 4 hours through these nursing interventions.

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    Assessment

    Uploaded by

    Mark Anthony Ibay
    54 views3 pages
    The patient reported pain from sutures as evidenced by a pain scale rating of 7 out of 10. Upon examination, the patient exhibited signs of pain including restlessness, irritability, cold clammy skin, excessive perspiration, facial grimacing, and increased respiration. The nurse's interventions included repositioning the patient, providing comfort measures, assisting with breathing techniques, ensuring a quiet environment, encouraging diversional activities, monitoring vital signs, and administering analgesics as ordered. The goal was to reduce the patient's pain to a level of 3 or less within 4 hours through these nursing interventions.

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    The patient reported pain from sutures as evidenced by a pain scale rating of 7 out of 10. Upon examination, the patient exhibited signs of pain including restlessness, irritability, cold clammy skin, excessive perspiration, facial grimacing, and increased respiration. The nurse's interventions included repositioning the patient, providing comfort measures, assisting with breathing techniques, ensuring a quiet environment, encouraging diversional activities, monitoring vital signs, and administering analgesics as ordered. The goal was to reduce the patient's pain to a level of 3 or less within 4 hours through these nursing interventions.

    Copyright:

    Attribution Non-Commercial (BY-NC)
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    54 views3 pages

    Assessment

    Uploaded by

    Mark Anthony Ibay
    The patient reported pain from sutures as evidenced by a pain scale rating of 7 out of 10. Upon examination, the patient exhibited signs of pain including restlessness, irritability, cold clammy skin, excessive perspiration, facial grimacing, and increased respiration. The nurse's interventions included repositioning the patient, providing comfort measures, assisting with breathing techniques, ensuring a quiet environment, encouraging diversional activities, monitoring vital signs, and administering analgesics as ordered. The goal was to reduce the patient's pain to a level of 3 or less within 4 hours through these nursing interventions.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 3

    ASSESSMENT

    DIAGNOSIS
    PLANNING
    NURSING INTERVENTION
    EVALUATION
    INTERVENTION
    RATIONALE

    SUBJECTIVE:
    “Msakit ang tahi ko”
    as verbalized by the
    patient.

    OBJECTIVE:

     Restlessness
     Irritability
     With cold

    clammy skin
     Excessive
    perspiration
     Facial
    grimace
     Increased
    respiration
    RR=26 bpm
     Pain scale =

    7: pain scaling
    of 1-10 where
    1 is the least
    painful and 10
    is the most
    painful

     Impaired
    thought

    Pain related to
    tissue trauma and
    incisional
    discomfort as
    manifested by
    grimace and pain
    scale =7.

    After 4 hours of
    nursing
    intervention
    patient’s pain
    evidenced by pain
    scale =7 be
    reduced to 3.

     Change the position


    of the patient
     Provide comfort
    measures
     Assist patient in
    breathing
    techniques
     Provide quiet
    environment
     Relay on the patient
    report of pain
     Encourage
    divertional
    activities
     Monitor vital sign
     Administer

    analgesic as
    ordered by the
    physician.

     Pain is

    sometimes due
    to the position
    of the patient

     To reduce the
    discomfort
     To assist in

    muscle and generalized relaxation

     For patient
    comfortabili-ty
    and lessen the
    discomfort.

     To reduce
    anxiety felt by
    the patient
     To divert the
    attention from
    pain to
    activities
     Usually altered
    in pain.
     To maintain
    acceptable level
    of pain.
     After 4 hours

    of nursing
    intervention
    the patient
    reported pain
    was lessened
    to pain s

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