Clarivel Jane E.

Matias Nursing Care Plan

Assessment S> Medyo sumasakit ang tahi ko kapag gumagalaw as verbalized by the client. pain scale: 5 P: pain rises upon moving. Q: stabbing pain R: pain radiates in the incision site in the abdomen S: mild (pain scale: 5) T: whenever she moves the pain lasted in 1-2 mins. O> vital signs taken as follows: BP: 120/80 mmHg Nursing Diagnosis Alteration in comfort pain related to tissue trauma secondary to removal of fallopian tubes. Scientific Explanation Due to surgical procedure done that needs a surgical incision there will be presence of trauma in the area that signals an actual tissue damage and inflammation, this damage will cause an inflammation of the nerves when the nerves are affected, there will be the presence of pain. Planning After 3 hours of nursing intervention the pain scale of 5 will decrease to pain scale of 3 and she will move comfortably. Interventions INDEPENDENT: 1. Assessed level of pain of the patient.

BSN IV-4 C

2. Monitored vital signs and recorded. 3. Provided rest and comfort measures. 4. Diversion of activities such as story telling. 5. Reduced stressful stimulants such as noise.

Evaluation The patients pain scale of 5 1. To decreased to determine pain scale of 3 what relief and the client felt measures is more appropriate comfortable as to evidenced by administer. performed 2. Provide activities like baseline going to CR data. alone and standing without 3. To satisfy assistance. the confinement of patient 4. To alter the patients pain. 5. To alter pain and diminish emotional

Rationale

Reference: http://nurseslabs.com /2010/03/nursingcare-plans/tahbso-

DEPENDENT:

Temp: 36.6 C PR: 92 bpm RR: 22 bpm Conscious and coherent. Facial grimace connotes pain. Facial grimace connotes discomfort. Guarding behavior to the incision site.

nursing-care-plans/ 6. Administered pain relief measures such as Mefinamic acid (Ponstan SF) and Morphine Sulfate as ordered by the physician.

stress

6. To maintain acceptable level of pain.

ASSESMENT Subjective data: Medyo inuubo ako Objective data: >productive cough >with CTT connected at H20 scaled drainage >facial grimace >coherent & conscious >adventitious breath sounds (crackles) Right lower lung

NURSING DIAGNOSIS Ineffective airway clearance related to retained secretions

SCIENTIFIC EXPLANATION

PLANNING

INTERVENTION

RATIONALE

EVALUATION

An accumulation After 4 hours of > Monitor vital signs > To obtain baseline data The patient has maintained of secretions can nursing for comparison clear airway and the block the airway in intervention, the > Advise to encourage > To help liquefy coughing activity was patients with an patient will increase fluid intake secretions lessened. upper airway maintain clear infection. As a airway and the > Position head appropriate > To open or maintain result, changes in cough will be for age/condition. open airway in at-rest or the respiratory lessened. compromised individual. pattern occur and > Elevate head of > To take advantage of the work of bed/change position every 2 gravity decreasing breathing hours & prn. pressure on the increases to diaphgram and enhancing compensate for drainage of/ventilation to the blockage. different lung segments. > To loosen and mobilize secretions. > Nebulization done. Reference: Pg.602 Brunner and Suddarths Textbook of Medical Surgical Nursing 11th edition