Assessment Diagnosis Rationale Planning Intervention Rationale Evaluation

S: “Msakit ang tahi Alteraion in Complex Goal: Assess vitals Elevated vital Goal:
ko” as verbalized comfort : Acute responses of After 8 hours of signs signs are After 8 hours of
by the patient. pain related to tissue and nursing indicative of nursing
tissue trauma nerve endings intervention pain. intervention
secondary to due to trauma patient will patient
O: surgical incision from surgery verbalize Assess pain For baseline verbalized
• Restlessness as manifested (incision) and decrease in characteristics, data for later decrease in
• Irritability by grimace and cause level of pain level and comparison and level of pain
• With cold pain scale =7. hypersensitivity from 7/10- causative to assert the from 7/10-
clammy skin to the central atleast 4/10. factors that cause of pain. atleast 4/10.
• Excessive nervous system casues pain.
perspiration that causes Objective: These signs Objective:
unpleasant After 1 hour of Assess surgical may indicate
• Facial
physical and health teaching site, for infection. After 1 hour of
grimace and
emotional patient will gain redness, health teaching
guarding
reactions and knowledge and swelling , patient gained
behavior on
responses. understand pain inflammation knowledge and
the
control and and itching. understood pain
abdomen.
management by Pain could be control and
• Surgical
demonstrating Turn and relieved by management by
incision site
management position patient. turning and demonstrating
is on
such as deep positioning. management
abdomen, no
breathing such as deep
purulent
exercises and Advice patient Ambulation breathing
discharge,
ambulation. to ambulate could help in exercises and
swelling or
often. healing of ambulation.
inflammation
surgical site
.
and relief of
• Increased pain.
respiration Teach patient to
RR=26 bpm do deep
• Pain scale = breathing
7: pain exercises.

*scale of 1-10 Teach patient to

where 1 is the least put pillow on
painful and 10 is abdomen when
the most painful coughing.

Administer
analgesics or
pain reliever as
ordered by the
physician.