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    Abril Enerva Mendoza
    The patient underwent exploratory laparotomy surgery and is experiencing postoperative pain. They report the pain as a 7 out of 10, located at the sternum and umbilicus, aggravated by coughing and movement. Vital signs show an elevated temperature of 38.2 C and signs of weakness and discomfort. The goals are to reduce the pain level to 5 out of 10 within 4 hours and maintain normal vital signs. Interventions include monitoring vitals, responding promptly to pain complaints, providing rest and eliminating stressors. After 8 hours of care the patient's pain level was reduced to 3 out of 10 and vital signs were stable.

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    Abril Enerva Mendoza
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    The patient underwent exploratory laparotomy surgery and is experiencing postoperative pain. They report the pain as a 7 out of 10, located at the sternum and umbilicus, aggravated by coughing and movement. Vital signs show an elevated temperature of 38.2 C and signs of weakness and discomfort. The goals are to reduce the pain level to 5 out of 10 within 4 hours and maintain normal vital signs. Interventions include monitoring vitals, responding promptly to pain complaints, providing rest and eliminating stressors. After 8 hours of care the patient's pain level was reduced to 3 out of 10 and vital signs were stable.

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    The patient underwent exploratory laparotomy surgery and is experiencing postoperative pain. They report the pain as a 7 out of 10, located at the sternum and umbilicus, aggravated by coughing and movement. Vital signs show an elevated temperature of 38.2 C and signs of weakness and discomfort. The goals are to reduce the pain level to 5 out of 10 within 4 hours and maintain normal vital signs. Interventions include monitoring vitals, responding promptly to pain complaints, providing rest and eliminating stressors. After 8 hours of care the patient's pain level was reduced to 3 out of 10 and vital signs were stable.

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    25 views3 pages

    Assessment

    Uploaded by

    Abril Enerva Mendoza
    The patient underwent exploratory laparotomy surgery and is experiencing postoperative pain. They report the pain as a 7 out of 10, located at the sternum and umbilicus, aggravated by coughing and movement. Vital signs show an elevated temperature of 38.2 C and signs of weakness and discomfort. The goals are to reduce the pain level to 5 out of 10 within 4 hours and maintain normal vital signs. Interventions include monitoring vitals, responding promptly to pain complaints, providing rest and eliminating stressors. After 8 hours of care the patient's pain level was reduced to 3 out of 10 and vital signs were stable.

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    ASSESSMENT S> Masakit pa rin yung sugat ko, dahil sa operasyon na ginawa sa akin O>-with intermittent gnawing pain

    n felt at the sternum to umbilicus area, lasting from 30 to 60 seconds aggravated by coughing and movement relieved by proper positioning, splinting, deep breathing. -with a pain scale of 7 out of 10 -client appears to be weak and uncomfortable -noted facial grimace - on NPO VS taken: temp: 38.2 C CR: 88 bpm PR: 86 bpm RR: 18 cpm BP: 100/70

    DEFINITIN OF THE PROBLEM Tissue Damage Activation of the peripheral Nervous System Activation of the central nervous system at the spinal cord level Transmission of the pain, Signal to the Brain

    GOAL STO: after 4 hours of nursing intervention the patient will be able to report and pain 5 on 7/10 scale and maintain vital signs to its normal range.

    INTERVENTION >Monitor vital signs. > Respond immediately to complaint of pain.

    RATIONALE > This will serve as a baseline data. >Prompt responses to complaints may result in decreased anxiety in the patient. > Periods of rest and sleep eliminate fatigue, and enable the patient to eliminate pain p erception. > This will help to alleviate pai n by giving comfort to them. > Stressors such as noise contribute to the feeling of irritability. > This would promote early healing of

    EVALUATION At the end of the 8 hours span of care, the patient was able experience on pain, as manifested by: a) VS taken: Temp: 38C CR: 69 PR: 67 RR: 18 BP: 100/70 b) with pain scale of 3

    PAIN

    LTO: after 8 hours span of care, the patient will be able to verbalize or report of >Provide emotio feeling nal support. comfort and pain 3 on 7/10 scale. > Eliminate stressors in the environment. > Maintain on bed rest.

    > Provide rest periods to facilitate comfort, sleep and relaxation.

    DIAGNOSIS: Acute pain related to tissue perfusion secondary to exploratory laparotomy.

    > Continue tramadol sidedrip as ordered.

    tissue. > Pain medications are absorbed and metabolize differently by patients, so their effectiveness must be evaluated individually by the patient. > Pressure contributes perception of pain. > Physician ordered NPO post op. > As distraction and reducing the tension at the incision site. > This exercise subsequently alleviates pain by relaxation.

    > Instruct to prevent pressure exerted over the incision area. > Instruct patient to maintain NPO. >Encourage to use diversional activities such as watching TV, listening to music, etc. > Encourage deep breathing exercises.

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