Name: T,MG Date of Admission : Sept.5,2011 Age : 19 Patient’s Health History :19 yrs old. G1P1T1A0L1 Religion : Roman Catholic Complaints : “sakit ako tahi day oie ..’’Occupation : housewife Gen. Objectives: After nursing intervention the patient will receive timely resolution with pain managementStatus: Married

NURSING CARE PLAN

NURSING DIAGNOSIS

SCIENTIFIC ANALYSIS OBJECTIVESNURSING

INTERVENTIONS RATIONALE EVALUATION VALUE INTEGRATION

Acute PainRelated toSurgical Incision in the perineal area

CUES:

Sub:

“ sakit akong tahi day oie.”

Objective;

-inflamation in the perineal area

.Acute pain isdescribed as anunpleasantsensory oremotionalexperienceassociated withactual orpotentialtissue damageor injury aslasting fromseconds to 6months. Incases offracture, painis continuous &increasing inseverity untilbone fragments

After 2 hours of nursing intervention the patient will be able to

- After 6 days ofnursingintervention,the patient:

-verbalizesminimized orcontrolledfeeling ofpain

-verbalizesmethods thatproviderelief

-Assess severity of pain using the pain scale

-Instructed todo activitiessuch as deepbreathingexercise,and perineal exercise

-advice diverting activities, such as watching tv

- Enough rest &sleep was alsoadvised.

-To find the patient’s own perception and description of pain

To reduce swelling& prevent stiffnessthe statedactivities must bedone.

- may lessen the body’s response and recognition to pain

-This promoteshealing by reducingbasal metabolicrate & allowingoxygen & nutrients

After 2 hours of nursing intervention the patient was able to: Pain isreduced/controlledto atolerableextent asverbalized.Relievingmethods &relaxationtechniquesareunderstood& demonstrated

Self- independence is a trait that we nurses should have to enhance our skills in critical thinking and decision skills to have a betterment in delivering care .

Self-efficacy is a trait that a nurse should have in order to obtain his/her goal in bringing the paramount care to his/her patient.

-grimace face duting exertion of force

areimmobilized. Inthis type offracture, themain medicalmanagement isopen reductionwith internalfixation(ORIF), whereinthe fracturefragments arereduced &internalfixationdevices areused to holdthe bonefragment inposition untilsolid bonehealing occurs.

-demonstratesuse ofrelaxationskills &diversionalactivities asindicated forhis situation

Long-term Goal

-After months ofnursingintervention,the patient: -is free ofpain on thesurgical sit

Dependent- Intake ofpain relieversuch asmefenamic acid& antibacterialmedicationssuch asamoxicillinas per doctor’sorder & advise

to be utilized fortissue growth,healing &regeneration.

-NSAID activityincludes modulationof T-cell function,inhibition ofinflammatory cellchemotaxis,decreased releaseof superoxideradicals, orincreasedscavenging of thesecompounds atinflammatory sites.Antibiotics areused to treat &prevent infectionscaused bysusceptiblepathogens in skinstructureinfections.