Assessment/ Cues Objective cues: weakness restless lack of energy Patient cannot tolerate walking; prefers to lie in bed.

bed. Child is observed to grimace, and open the eyes wide sometimes. Vertical incision sealed with 7 small separate sutures midline of abdomen covered with wound dressing. A space between suture 3 & 6 holds a gauze soaked in Betadine inside the abdominal cavity. Green pus was seen draining out of the abdomen.. Siguro 8 (10 highest) masakit pa rin. Unequal muscular strength on both sides. Subjective cues: During hospitalization, he was not also able to have exercise. His mother would just change his position every

Nursing Diagnosis Acute pain related to impaired tissue integrity as manifested by pain scale 8/10.

Analysis Pain is a typical sensory experience that may be described as the unpleasant awareness of noxious stimulus or bodily harm.

NURSING CARE PLAN 1: ACUTE PAIN Goals and Nursing Objectives Interventions After 8 hours of nursing intervention, the clients pain will be lessened and managed. Objectives: After nursing intervention, the patient will display less objective cues of pain. Perform a comprehensive assessment of pain to include location characteristics onset, duration, frequency, quality, intensity or severity in precipitating factors of pain. Teach the used of non-pharmacologic technique (deep breathing exercises, distractions)

Rationale

Evaluation After 8 hours of nursing intervention, the clients pain was lessened and managed.

Pain is subject experience must be described by the client in order to plan effective treatment. NANDA

After 10 minutes the client will be able to perform techniques of pain management.

The use of noninvasive pain can increase the release of endorphins and enhance the therapeutic effect of pain relief medication. Brunner & Suddarths Textbook of Medical-Surgical Nursing, 12 Ed., vol.1, chapter 13 To provide comfort to the client, to promote circulation and prevent tissue pressure. NANDA To promote blood circulation and faster healing of incision. NANDA To prevent further infection. NANDA

Position the client to where he is comfortable. Instruct the client to have a short walk as tolerated everyday as a form of exercise. After 5 minutes of nursing intervention the clients guardian will be able to perform the proper wound care. After nursing intervention, the patient will be able to receive medications Assist and provide health teaching in the change of wound dressing at surgical site. Administer Ibuprofen 100 g/5 ml or 8 ml Q8 PRN for pain.

Ibuprofen is an NSAID that is often used to relieve pain. It may however cause bleeding. Springhouse 2008 Drug