Patient: J.S.

Admitting Diagnosis: Post-Debridement with Jackson Pratt Drain Assessment Actual/Abnormal cues Patient complained, Gasakit ang ulo ko (+) Guarding behavior of putting his arm on his head part Has a facial expression like that of a beaten look face Patient seen changing position every now and then Pain scale of 6 Risk/Risk Factors Presence of Jackson Pratt drain in the head Strengths Strong family support Nursing Diagnosis Acute pain related to presence of postoperative surgical incision as evidenced by verbal report of pain at head part, guarding behavior, and facial mask [beaten look]. Definition: Unpleasant sensory and emotional experience arising from actual/ potential tissue damage or described in terms of such damage (International Association for the study of Pain); sudden/slow onset of any intensity from mild to severe Rationale Multiple hack wound at the temporoparietal and neck area due to mechanical trauma Desired Outcomes After 3 hours of nursing interventions, the patient will be able to: 1.)Report pain is relieved/ controlled. Nursing Interventions Justifications Evaluation After 3 hours of nursing interventions, the patient was able to:

1.1 Assess for referred pain, as appropriate

Undergone surgical intervention of debridement with Jackson Pratt drain

Inflammation of surgical wound as part of healing process / wearing off of anesthetic substances

1.2 Obtain client assessment to pain including location, characteristics, onset/duration, intensity, precipitating and aggravating factors. Reassess each time pain occurs/is reported. 1.3 Monitor skin color/ temperature and vital signs

1.1 To help determine possibility of underlying condition or organ. 1.2 To rule out worsening of underlying condition/ development of complications.

1.) Goal met. Verbalized, waay naman gasakit kag gahubag akon ulo. No signs of inflammation on the surgical wound such as presence of erythema and swelling.

1.3 Which are usually altered in acute pain

 Good compliance to treatment and medications

with an anticipated or predictable end and a duration of less than 6 months. Source: Doenges, M.E, et. Al. Nurses Pocket Guide Edition 11. F.A. Davis Company. Philadelphia, Pennsylvania. 2008.

2.)Follow Acute pain prescribed related to pharmacological postoperative regimen. surgical incision Source: MedicalSurgical Book Edition 16 by Williams and Wilkins.

2.1 Administer analgesics, Paracetamol and Celecoxib, as indicated to maximum dosage as needed.

2.1 To maintain acceptable level of pain. Notify physician if regimen is inadequate to meet pain control goal. 2.2 increasing/ decreasing dosage, stepped program helps in selfmanagement of pain. 3.1 to promote nonpharmacological pain management

2.) Goal met. Complied in taking medications on time such as Paracetamol 500 mg 1 tab PO PRN and Celecoxib 200 mg 1 cap OD for pain relief

2.2 evaluate/ document clients response to analgesia, and assist in transitioning/ altering drug regimen, based on individual needs. 3.)Demonstrate use of relaxation skill and diversional activities as indicated for individual situations. 3.1 provide comfort measures (e.g., touch, repositioning, nurses presence), quite environment and calm activities. 3.2 instruct in/encourage use of relaxation techniques such as focused breathing, imaging. 3.3 encourage having adequate rest periods.

3.2 to distract attention and reduce tension

3.3 to prevent fatigue

3.) Goal met. Demonstrated use of relaxation skills and diversional activities by elevating his injured part (head) to 30 degree angle, practice calm activities (moving slowly when getting up on bed and turning from side to side) and having adequate rest periods such as taking a nap.