subjective cues:

" i can feel pain in my chest area" acute pain related to post op procedure

interventions
planning 1. monitor pt. v/s & skin color
objective Cues: 2. Assess for referred pain , as appropriate.
3. note location of surgical procedures
4. Determine the patient’s anticipation for pain
Receive pt. lying on bed with #3 PLR 1L regulated @ 30 relief.
within 8 hrs of nursing intervention pt. 5. evaluate characteristics of pain using pain
gtts/min, will be able to : scale
hooked at L metacarpal vein, intact. receive @ 300 cc level.  verbalize pain relief 6. give medications as ordered by the physician
with ongoing Blood Transfusion #1 PRBC with segment rates pain scale lower than 9/10
number 8600-00123-476 Type O (+) regulated at KVO rate.
with 3-way drainage CTT in place.
with oxygen supplementation via nasal cannula at
2LPM. 
post op  evaluation
has difficulty of breathing
dyspnea
rationale
pale looking
limited interaction after 8 hrs of nursing intervention pt.
rates 9/10 from pain scale 
 Guarding behavior noted was able to : 1. to check for any alterations
chest indrawing verbalize pain relief 2. to help determine possibility of underlying
condition or organ dysfunction requiring treatment
splinting unequal lung expansion rates pain 6/10 from pain scale 3. to determine the amount of postoperative pain.
right side expanded than left side vital signs as follows: 4. This influences the perceptions of the
RBC 3.5 effectiveness of the treatment of the treatment
wbc 11.0 t: 36.4 modality and their eagerness to engage in further
V/s as follows: PR 130 Bpm pr: 95 treatments.
5. to demonstrate improvement in status or to
RR 38 bpm rr; 20 identify worsening of underlying conditions
BP 80/60 developing complications
T 35.7 BP: 90/60 6. this helps in managing acute pain
O2 sat: 90% o2 sat: 96%