CUES

NURSING
DIAGNOSIS

INFERENCE

GOALS

Subjective:
- Masakit
yung
inoperahan sa
akin lalo
kapag unting
galaw lang,
sobrang
kumikirot. as
verbalized by
the patient.

Acute Pain
related to
tissue injury
secondary to
surgical
intervention

Surgical
Intervention
(Exploratory
Laparotomy)

Tissue trauma
and injury

Numerous
nerve ending
damage

Pain on the
abdomen
centralized in
the incision
site

Patient
becomes
restless and
irritable, facial
grimace is
seen

Patient fears
the pain will
increase there
by showing a
protective
behaviour by
guarding the
incision sight

Short Term:
After 30-45
minutes
of nursing
interventions,
the patient
will be able
to:

Objective:
- Restlessness
- Irritable
- Facial
grimace
- Guarding
behavior on
the abdomen
(incision site)

1.
Demonstrate
use
of relaxation
skills and
diversional
activities
2. Report
slightly
or totally
relieved by
verbalizing it.
3. Be slightly
or totally
comfortable
and less
irritable
4. Shows less
or no
guarding
behaviour

NURSING
INTERVENTI
ONS
Independent:

RATIONALE

- Perform
comprehensiv
e assessment
each time
pain occurs

- Pain is
subjective
experience
and must be
described by
client in order
to plan
effective
treatment

- Provide back
rubor position
the client to
his comfortabl
e position
- Instruct in
use
of relaxation
exercise such
as pursed lip
breathing
- Encourage
diversional
activities such
as reading his
favourite book
or socializing
with relatives
- Application
of dressing

- To provide
comfort and
relaxation

- To promote
relaxation

- To divert the
attention from
pain

EVALUATION
Short Term:
Goal was fully
met after 45
minutes
of nursing
interventions,
the patient
was be able
to:
1.
Demonstrate
use
of relaxation
skills and
diversional
activities
2. Report
slightly by
verbalizing
Mas
nabawasan na
yung kirot
compare
kanina.
3. Be slightly
comfortable
and less
irritable

- To promote

4. Shows less

on the
abdomen
Reference:
Principles of
Med-Surg
Vol.14th
edition by
Lemone and
Burke

Long Term:
After 5-7
days of
nursing
intervention,
the patient
will be able
to:
1. Shows sign
of healing in
the incision
site
2. Reports
relieve from
pain
3. Feels
comfortable

and
abdominal
binder
- Create a
quiet and
nondisruptive
environment
- Encourage
adequate rest
periods

healing and
minimize pain

guarding
behaviour

- Provide
comfort and
relaxation
for the client

Long Term:
Goal was fully
met after 6
days of
nursing
intervention,
the patient
was able to:

- To prevent
fatigue

Dependent:
- Administer
analgesic
(Tramadol HCl
50 mg TIV,
Ketorolac 30
mg TIV) as
ordered

- To inhibit
synthesis
of prostagland
in

1. Shows sign
of healing in
the incision
site
2. Reports
relieve from
pain
3. Feels more
comfortable