LIST OF IDENTIFIED PROBLEMS
1. Acute pain related to tissue trauma secondary to surgical procedure
2. Powerlessness related to early loss of pregnancy secondary to ectopic
pregnancy.
3. Rick for infection related to related to breakdown of the body's first line of
defense.
4. Impaired skin integrity related to tissue trauma secondary to surgical
procedure
5. Activity intolerance related to body weakness.
PRIORITIZATION OF PROBLEMS
Nursing Diagnosis Rationale
Acute pain related to tissue trauma secondary
to surgical procedure
It is a high priority since my patient
verbalized a 7/10, 10 as most severe. Other
problems below are underlying problems
caused by pain.
Impaired skin integrity related to tissue
trauma secondary to surgical procedure
This is the second because following ABC
this falls down in Circulation. But although
there may be an alteration in the patients
circulation, it is not that much.
Activity intolerance related to body
weakness.
This is the third since this falls in Basic
needs of Maslows hierarchy of needs. It is
because physical activity can be accomplished
with intact and functioning neuromuscular
and skeletal systems.
Powerlessness related to early loss of
pregnancy secondary to ectopic pregnancy.
This is the fourth since this belongs to Love
and belongingness of Maslows Hierarchy of
needs. The mother lost a child to be cared and
loved.
Rick for infection related to related to
breakdown of the body's first line of defense.
This is the fifth since this is just a risk and we
can do intervention to prevent this from
happening.
NURSING CARE PLAN
Assessment:
Problem: Postoperative Pain
Subjective Data:
Nu agpagpagna ak ket nasakit jay sugat ko pati metlang nu
agtugtugaw ak
Rated pain as 7/ 10, 10 being most severe, characterized as dull,
localized over wound, intermittent and aggravated by movement.
Obejective Data:
T: 37.1 C
BP: 100/ 60
PR: 113 bpm
RR: 28 bpm
With good skin turgor and 1-2 seconds capillary refill
With an abdominal binder in place
Guards abdominal area and grimaces noted.
Nursing Diagnosis: Acute pain related to tissue trauma secondary to post surgical
procedure.
Explanation of the Problem:
Ectopic pregnancy is a possible cause of severe abdominal pain in the first
trimester. This happens when the egg implants inside the fallopian tubes
or elsewhere outside the uterus. The first sign a woman may notice is
vaginal bleeding followed by lower abdominal pain that intensifies with
time. Vomiting, dizziness, and shoulder pain could also occur. It is very
important for a woman experiencing these symptoms to get medical
attention as soon as possible wherein there will be a need for eplore
laparotomy and salpingectomy. The abdominal pain associated post
status salphingectomy may be described as cramping or severe
continuous pain. Pain is a typical sensory experience that may be
described at the unpleasant awareness of a noxious stimulus or bodily
harm.
Reference: Med-Surg by BRUNNER SUDDARTH pages 1404
Goals/ Objectives:
Short Term Objective:
After 8 hours of nursing intervention, the patient will be able to rate pain
from 7/ 10 to 2/10, 10 being most severe.
Long Term Objective:
After 3 days of nursing intervention, the patient will be able to verbalize
absence of pain.
Goal: The patient will be free of pain on the surgical site.
Interventions Rationale
Dx.
Assessed vital signs and dressings
Assessed for pain using PQRST.
Tx.
Independent:
Provided additional comfort
measures like back rub
Communicate with patient
Dependent:
Increase in BP and CR
indicates patient is in pain.
Moistened dressings are
favorable site for
microorganisms to culture
and if there would be
inflammation, it would cause
pain at the incision site.
Pain is a subjective
experience; experience of
pain can be answered through
verbalization.
This can be explained by Gate
Theory wherein the
transmission painful impulses
to the level of consciousness
are being inhibited by the
closure of the gate blocking
these sensations.
Attention can be diverted,
letting the focus on other
stimulus.
Intake of pain relievers as per
doctors order and advise
Celecoxib(Celebrex) 200mg 1
tab BID
Classification: Analgesic
MOA: inhibits cyclo-oxgenase
2 which is responsible for
prostaglandin synthesis;
reduces inflammation and
relieves pain.
Nursing Consideration: Take
in preferably with food and
full glass of water to prevent
GI upset.
Edx.
Encouraged use of relaxation
technique like deep breathing
exercises
Recommended planned or
progressive exercise
NSAID activity includes
modulation of T-cell function,
inhibition and inflammatory
cell chemotaxis, decreased
release of superoxide, radicals
or increased scavenging of
these compounds at
inflammatory sites.
There would be a better
perfusion / circulation of
blood providing adequate
oxygen to the traumatized
tissue therefore inhibiting
pain to occur.
Prevents undue strain on
operative site. Promotes
return of normal function and
enhances feelings of general
well being. It relieves pain by
Encouraged enough rest and sleep
Noted to avoid weight bearing until
allowed
diverting her attention not
focusing on her postoperative
pain.
Pain can be prevented by
reducing basal metabolic rate
and allowing oxygen and
nutrients to be utilized for
tissue growth and
regeneration to prevent
inflammation of the wound
which causes pain.
Avoid straining of the sutures
which may
possibly cause pain, activities
that may extend the cut must
then be avoided.
References:
Med-Surg by Brunner Suddarth pages 1404 1406
Maternal and Child Health Nursing by Pillitteri pages 559 - 560
Evaluation:
Objective partially met as evidenced by the verbalization of patient rating pain as 3/
10, 10 being most severe.
