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Javier, Janna Gale G.


Incarcerated Inguinal Hernia (IIH)

Rationale of the
Cues Nursing Diagnosis Rationale Goal Nursing Intervention Nursing Evaluation
Subjective Acute pain related Pain is a highly Short Term Independent Functions Goals partially
to surgical subjective state met.
“I feel less pain in procedure as in which a Patient will Assess the patient’s pain by Single- item ratings of
surgical incision on manifested by variety of verbalize pain less using the 10 point pain pain intensity are Continue
the right side but not patient unpleasant than 4 or 0, on a rating scale q4 hrs or PRN valid and reliable as interventions as
radiating to left side. verbalization sensations and a 0-10 pain rating during the 2-10pm shift. measures of pain listed.
(Medyo makirot pa wide range of scale by end of 2- intensity.
rin po ung tahi ko sa 10pm shift. Continue to
kanan pero wala The client’s report of assess pain using
factors may be
namang sakit sa After performing pain is the single most the 10 point pain
experienced by
bandang kaliwa ng the nursing reliable indicator of scale q4 hrs or
sugat.)”, as the patient.
interventions, pain. PRN.
verbalized by the patient will (Ackley & Ladwig,
patient. Without adequate
experience relief. 2008, p. 604-605). Continue to
pain management,
provide pain
Patient’s daughter it may interfere
Have the patient splint the Splinting and proper control and treat
mentioned that his with patient’s
incision site with hand or positing reduce the as needed.
father cannot move ability to perform
pillow when coughing to stress on the incision
freely without pain ADL’s, progress
lessen pain and protect site area. The patient
and needs assistance towards healing,
from increased reported relief
to get down from the and patient’s
intraabdominal pressure. from a 4 to 2 on
bed. participation in
a 0 – 10 pain
treatment plan.
Before any activities, treat Pain limits mobility rating scale after
Objective pain. and is often the 2 – 10 shift.
exacerbated by
Patient states that his movement. (Ackley &
abdominal pain level Ladwig, 2008, p 552).
is a 4 on a 0 – 10
point pain rating Explaining and teaching These relaxation
scale. nonpharmacologic pain techniques decrease
relief methods, such as oxygen consumption,
Patient’s blood breathing exercises, music respiratory rate, heart
pressure changes therapy, distraction and rate, and muscle
from normal baseline progressive relaxation tension, which
data but heart and before, after, and if possible interrupt the cycle of
respiration rate during painful activities. pain–anxiety–muscle
remain regular and tension.
Reduce or eliminate factors Personal factors can
Patient’s midline that precipitate or increase influence pain and
abdominal incision patient’s pain experience pain tolerance.
appears dry and (e.g., fear, fatigue, and lack Factors that may be
intact. of knowledge) precipitating or
augmenting pain
Patient show should be reduced or
grimaces eliminated to enhance
occasionally during the pain management
any kind of motion or program.
movement of his
body. Keep side rails up and bed This promotes a safe
in low position. environment.
Patient’s feet are
twitching when Frequent repositioning of To prevent back pain
incision is being the patient when lying in and bedsores at the
cleansed. bed. back, sacrum and