Cues Subjective: Masakit ung tahi sa pwerta ko Objective: (+)Facial grimace Reduced interaction with the environment Cold

Cold sweats Elevated BP of 130/100 Pain scale of 5/10

Nursing Diagnosis Acute Pain related to surgical incision as manifested by: (+) Facial Grimace, reduced interaction with the environment, elevated BP of 130/100, cold sweats and pain scale of 5/10

Goals and Objectives After 8 hours of Nursing Intervention the client will be manifest a decrease in pain scale from 5/10 to 3/10 or lower

Intervention

Rationale

Evaluation After the nursing intervention: Did the client able to manifest a decrease in pain scale from 5/10 to 3/10 or lower? Yes___ No_______ If No, Why? __________

Objectives: After 8 hours of nursing intervention the client will be able to: Verbalize needs and perceptions Build rapport with the client Assess for the clients level of understanding, perception and needs Obtain clients Baseline VS. including pain scale To be able to identify the interventions that needs to be done To be able to assess for future comparison Did Verbalize needs and perceptions Yes___ No_______ If No, Why? ___________

Verbalize comfort

Position the client in To provide comfort bed to where she is and safety comfortable and provide safety Teach the client diversional activities. To divert the attention of the patient from the pain

Did the client Verbalize comfort Yes___ No_______ If No, Why? ___________ Did the client able to Divert her attention to other activities Yes___ No_______ If No, Why? ___________ Did the client able to manifest a decrease of pain form 5/10 to 4/10 or lower Yes___ No_______ If No, Why? ___________

Divert her attention to other activities

Verbalize decrease of pain form 5/10 to 4/10 or lower

Administer Analgesic (Mefenamic Acid) as prescribed by the physician

This will alleviate pain