Problem identified: Abdominal Pain secondary to Caesarian Section Nursing Diagnosis: Altered comfort-acute pain related to surgical incisions

Taxonomy: Cognitive-Perceptual Pattern Cause analysis: CUES OBJECTIVES NURSING INTERVENTIONS

SUBJECTIVE: Gasakit pa jud kayo akong tiyan kay bg-o lng ko nanganak (Patient verbalized) STO: After 2-4 hours of giving nursing interventions, the patients pain decreases on a pain scale of 1-10 with pain less than 2, as evidence of the absence of facial grimace and feeling of relaxation. LTO: OBJECTIVE: >facial grimace >general weakness >restlessness After 8 hours of giving effective nursing intervention, the patients level of pain is 0 and is able to sleep or rest appropriately. INDEPENDENT: >Reassure patient that you know pain is real and will assist her in dealing with it. >Assess and record pain and its characteristics: location, quality, frequency and duration. >Encourage relaxation exercise such as deep breathing exercise when pain occurs. >Review factors that aggravate or alleviate pain. >Provide comfort measures and diversional activities. > Promote bed rest, allowing the patient to assume position of comfort.

RATIONALE

EVALUATION

STO: >Fear that pain will not be After 2-4 hours of giving accepted as real increases nursing interventions the tensions, anxiety and decreases patients level of pain is pain tolerance. improved. > Data assist in evaluating pain and pain relief and identifying multiple sources and types of pain. >Promotes relaxation, refocuses attention, and may enhance coping abilities. LTO: >Helpful in establishing After 8 hours of duty the diagnosis and treatment needs. patients level of pain is > This contributes pain, relief relieved and appears relaxed. muscle tension and anxiety whenever patient naturally assume least painful position.

DEPENDENT: >Prove and implement prescribe >Patient may receive nothing by dietary medications. mouth (NPO) initially. When oral intake is allowed, food choices depend on the diagnosis >Administer medications if >Analgesics are more effective if indicated administered early in pain cycle. e.g. Analgesics