ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Data: Acute pain related to post Short term: Independent: GOAL PARTIALLY MET.
“Masakit gid di sa akon mastectomy as evidenced
may hiwa dampi.” as by facial mask of pain, After the 8 hours of Assess the client for signs Early recognition of signs  After 8 hours of
verbalized by the patient. redness in the incision site, nursing intervention the and symptoms of pain and symptoms of pain rendering
and elevated vital signs. patient will be able to: frequently during the allow prompt intervention. appropriate
Objective Data:  Report pain course of the procedure nursing
>Post simple mastectomy relieved or interventions, the
right breast controlled at a Provide Promotes relaxation, helps client’s pain scale
> Grimace noted satisfactory level nonpharmacological refocus attention, and may was decrease from
>Redness in the incision with a pain scale comfort measures like enhance coping abilities. 7/10 to 4/10.
site of 3/5 repositioning, backrub and  Patient was able
>Pain Scale: 7/10 diversional activities like to rest and
>Vital Signs Long term: playing music, and participate in
 Temp: 37.2 C television. some of the
 RR: 21 bpm activities
 PR: 92 bpm After 24-48 hours of Encourage early Relieves muscle and  Vital Signs:
 BP: 140/90 nursing intervention the ambulation and use of emotional tension; Temp: 36.8 C
patient will be able to: relaxation techniques, enhances sense of control RR: 19 bpm
 Rest and guided imagery, and and may improve coping PR: 90 bpm
participate in therapeutic touch. abilities. BP: 130/90
activities
appropriately. Assess vital signs, noting Changes in these vital
 Demonstrate use tachycardia, and increased signs often indicate acute
of relaxation skills respiration, even if patient pain and discomfort. Some
and diversional denies pain. patients may have a
activities as slightly lowered BP, which
indicated for return to normal range
individual after pain relief is
situation. achieved.

Assess causes of possible

discomfort other than
preoperative procedure. Discomfort can be caused
or aggravated by presence
of non-patient indwelling
catheters, NG tube,
parenteral line, infiltration
of IV fluids etc.

Dependent:
Administered tramadol
50mg as ordered.