CUES/DATA Subjective: Ang sakit ng kanang puson ko, as verbalized by the patient with a pain scale of 7 out of 10 Objective:

BP: 160/80 PR: 80 bpm Irritabil ity Grimac e Incisio n on right lower umbilicus

DIAGNOSIS Pain related to surgery incision (radical prostectomy) as evidenced by verbalization of pain and facial grimace.

RATIONALE Physical stimuli (incision of the skin) Stimulates nerve endings in the skin (norciceptors) Transmission of pain perceptions to the brain Pain Reference: Brunner and Suddarths Textbook of Medical-surgical Nursing 12th ed.

GOALS & OBJECTIVES After 2 hours of effective nursing intervention, the pain scale will decrease from 7 to 3.

INTERVENTIONS
Encourage noninvasive pain management techniques such as guided imagery, relaxation and distraction Monitory clients vital signs. Explain alternative therapies such as hypnosis Provide cold application on the clients nose Provide adequate rest for the client Relieve or prevent factors that aggravate pain (e.g., coughing) Administer analgesic as ordered by the physician.

RATIONALE
To reduce focus on pain and increase other impulses, which may help block pain impulses Assessment of vital signs allows the health care provider to understand a patients physiologic status and is helpful in determining appropriate goals. It may stimulate brain opiates or produce a psychological effect This may relieve edema and may produce anesthesia Rest promotes healing. To reduce the onset of pain To help reduce or eliminate the pain

EVALUATION After 2 hours of effective nursing intervention, the goal was met by decrease of pain scale from 7 to 3.