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    Assessment Nursing Diagnosis Scientific Explanation Planning Intervention Rationale Evaluation Indeoendent

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    Diane Sarino Cabonce
    The nursing assessment identified that the patient was experiencing acute pain from post-surgical procedures as evidenced by restlessness, stabbing pain upon movement, weakness, excessive sweating, and a pale face with facial grimaces. The plan was for independent nursing interventions including evaluating the characteristics of the pain, potential causes, and providing comfort measures to help gradually reduce the pain and improve the patient's wellbeing. Dependent interventions included evaluating the effectiveness of pain control, ensuring sufficient pain medication was administered, and assisting with patient-controlled analgesia or epidural catheter administration.

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    Assessment Nursing Diagnosis Scientific Explanation Planning Intervention Rationale Evaluation Indeoendent

    Uploaded by

    Diane Sarino Cabonce
    164 views3 pages
    The nursing assessment identified that the patient was experiencing acute pain from post-surgical procedures as evidenced by restlessness, stabbing pain upon movement, weakness, excessive sweating, and a pale face with facial grimaces. The plan was for independent nursing interventions including evaluating the characteristics of the pain, potential causes, and providing comfort measures to help gradually reduce the pain and improve the patient's wellbeing. Dependent interventions included evaluating the effectiveness of pain control, ensuring sufficient pain medication was administered, and assisting with patient-controlled analgesia or epidural catheter administration.

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    NCP2-LUNG-CANCER

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    The nursing assessment identified that the patient was experiencing acute pain from post-surgical procedures as evidenced by restlessness, stabbing pain upon movement, weakness, excessive sweating, and a pale face with facial grimaces. The plan was for independent nursing interventions including evaluating the characteristics of the pain, potential causes, and providing comfort measures to help gradually reduce the pain and improve the patient's wellbeing. Dependent interventions included evaluating the effectiveness of pain control, ensuring sufficient pain medication was administered, and assisting with patient-controlled analgesia or epidural catheter administration.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    164 views3 pages

    Assessment Nursing Diagnosis Scientific Explanation Planning Intervention Rationale Evaluation Indeoendent

    Uploaded by

    Diane Sarino Cabonce
    The nursing assessment identified that the patient was experiencing acute pain from post-surgical procedures as evidenced by restlessness, stabbing pain upon movement, weakness, excessive sweating, and a pale face with facial grimaces. The plan was for independent nursing interventions including evaluating the characteristics of the pain, potential causes, and providing comfort measures to help gradually reduce the pain and improve the patient's wellbeing. Dependent interventions included evaluating the effectiveness of pain control, ensuring sufficient pain medication was administered, and assisting with patient-controlled analgesia or epidural catheter administration.

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    ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATI

    DIAGNOSIS EXPLANATION
    Subjective: INDEOENDENT:
    After series of  Ask the patient about  Helpful in evaluating cancer- After serie
    Objective: An acute pain in nursing pain. Determine pain related pain symptoms, which nursing
     Restlessnes Acute pain r/t the surgical incision intervention characteristics: may involve viscera, nerve, or interventi
    s tissue trauma from post-surgical patient will be continuous, aching, bone tissue. Use of rating scale patient
     Knife like as evidence by procedures is the able to stabbing, burning. Have aids the patient in assessing experienc
    stabbing distraction results to an experience patient rate intensity on a the level of pain and provides gradua
    pain upon behaviors. unpleasant sensory gradual 0–10 scale and assess a tool for evaluating the reduction
    movement. and emotional reduction to patient’s verbal and effectiveness of analgesics, relieved p
     Weakness experience since relief from pain nonverbal pain cues. enhancing patient control of and displa
     Excessively there is damage or and will display pain, the discrepancy between improve
    sweating injury in the tissue improve verbal and/or nonverbal cues wellbein
     Pale face that may be wellbeing such may provide clues to the
     With facial described as the as relax muscle. degree of pain, need for or
    grimace unpleasant effectiveness of interventions.
    awareness of a  Note possible  Fear, distress, anxiety,
    noxious stimulus or pathophysiological and and grief over the confirmed
    body harm, psychological causes of diagnosis of cancer can impair
    experience pain by pain. the ability to cope. The
    various daily hurts presence of chest tubes can
    and aches, greatly increase discomfort.
    occasionally  Encourage verbalization of  Fears or concerns can
    through more feelings about the pain. increase muscle tension and
    serious injuries or lower threshold of pain
    illnesses. perception.
     Provide comfort  Promotes relaxation and
    measures: frequent redirects attention. Relieves
    changes of position, back discomfort and augments
    rubs, support with pillows. therapeutic effects of
    Encourage use analgesia.
    of relaxation techniques,
    visualization, guided
    imagery, and appropriate
    diversional activities.

     Assist with self-  Prevents undue fatigue and


    care activities, breathing incisional strain.
    and/or arm exercises, and Encouragement and physical
    ambulation. assistance and support may be
    needed for some time before
    the patient is able or confident
    enough to perform these
    activities because of pain or
    DEPENDENT: fear of pain.

     Evaluate effectiveness of  Pain perception and pain relief


    pain control. Encourage are subjective thus, pain
    sufficient medication to management is best left to the
    manage pain, change patient’s discretion. If the
    medication or time span patient is unable to provide
    as appropriate. input, the nurse should
    observe physiological and
    nonverbal signs of pain and
    administer medications on a
    regular basis.
     Assist with patient-  Maintaining a constant drug
    controlled analgesia (PCA) level avoids cyclic periods of
    or analgesia through the pain, aids in muscle healing,
    epidural catheter. and improves respiratory
    Administer intermittent function and emotional
    analgesics routinely as comfort and coping
    indicated, especially 45–
    60 min before respiratory
    treatments, deep-
    breathing or coughing
    exercises.

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