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Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation

A nurse assessed and cared for a client who had undergone exploratory laparotomy surgery. The client reported a pain level of 4 out of 10. Objective findings included a blood pressure of 150/90, a facial grimace, and guarding behavior. The nurse diagnosed the client with acute pain related to the surgical incision. The nurse's plan was for the client's pain level to decrease to 1 out of 10 within 4 hours. Interventions included assessing and monitoring the client's pain signs and symptoms, identifying the cause of pain, eliminating stressors, providing rest, and administering prescribed analgesics. After 4 hours the client's pain level decreased to 1 out of 10 as evidenced by improved vital signs and less grima

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1K views3 pages

Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation

A nurse assessed and cared for a client who had undergone exploratory laparotomy surgery. The client reported a pain level of 4 out of 10. Objective findings included a blood pressure of 150/90, a facial grimace, and guarding behavior. The nurse diagnosed the client with acute pain related to the surgical incision. The nurse's plan was for the client's pain level to decrease to 1 out of 10 within 4 hours. Interventions included assessing and monitoring the client's pain signs and symptoms, identifying the cause of pain, eliminating stressors, providing rest, and administering prescribed analgesics. After 4 hours the client's pain level decreased to 1 out of 10 as evidenced by improved vital signs and less grima

Uploaded by

MikhaelEarlSantosTacorda
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Date: September 21, 2012

Case: Post-op Exploratory Laparotomy



ASSESSMENT
NURSING
DIAGNOSIS
PLANNING
NURSING
INTERVENTION
RATIONALE EVALUATION

SUBJECTIVE
DATA:

Medjo masakit ang
sugat ko as stated
by the client. The
client graded the
pain 4 out of 10
from the pain scale
of 1-10 in which 10
is the worst possible
pain.

OBJECTIVE
DATA:

with blood
pressure of
150/90

with facial
mask of pain
(grimace)

with
guarding
behavior

narrowed

Acute pain related to
damaged physical
integrity secondary
to surgical incision
as evidence by
account of pain from
the client

SHORT TERM:
After 4 hours of
nursing
intervention the
client will manifest
diminish level of
pain as evidence
by pain scale of 4
out of 10 to 1 out
of 10, decrement
of blood pressure
and absence of
facial grimace.

INDEPENDENT
INTERVENTIONS

1. Assess pain
characteristics





2. Observe or
monitor signs
and symptoms
associated with
pain such as
blood pressure,
heart rate,
temperature,
and ability to
focus


3. Distinguish the
cause of pain









1. Assessment of
the pain
assists in
planning
management
strategies.

2. Monitoring of
associated
signs may
help in
evaluating
pain and
measuring its
degree.




3. Identifying
the cause of
pain aids in
choosing the
type of
intervention
that is to be

After 4 hours of
nursing
intervention the
clients level of
pain was reduced
as evidence by
decrease level of
blood pressure
from 150/90 to
130/90, absence
of facial grimace
and clients report
of diminished
level of pain from
4 out of 10 to 1
out of 10.

Goal was met.
Date: September 21, 2012
Case: Post-op Exploratory Laparotomy

focus as
demonstrate
d by
withdrawal
from social
contact




4. Identify the
factors that
may contribute
to occurrence
of pain




5. Eliminate
additional
stressors or
sources of
discomfort.












6. Provide rest
period to
facilitate
comfort and
carried out to
the client.

4. Appraisal to
the factors
that
contributes to
occurrence of
pain may help
to eliminate
the cause.

5. In the
presence of
stressors and
sources of
discomfort the
clients
threshold of
pain
decreases,
elimination of
these factors
may help in
increasing the
ability of
client to cope
with pain.

6. Absence of
rest during
periods of
pain may
Date: September 21, 2012
Case: Post-op Exploratory Laparotomy



relaxation.







DEPENDENT
INTERVENTIONS

1. Administer
analgesic as
prescribed






aggravate the
level of pain.









1. An analgesic
inhibits the
prostaglandin
synthesis, an
agent that
causes pain
thereby
producing
anti-
inflammatory
effect and
relieving the
pain.

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