IMPLEMENTATION ASSESMENT NURSING DIAGNOSIS Pain related to tissue trauma secondary to (TAH) Total Abdominal Hysterect omy.

PLANNING NURSING INTERVENTION Independent: Provide Comfort measures like helping patient assume position of comfort. Suggest use of relaxation technique and deep breathing exercises. Encourage early ambulation Encourage divertional activities like waching T.V. or reading books. Promotin g relaxati on enhances coping abilitie s. RATIONALE EVALUATI ON After 8 hours of nursing interven tions Goal is complete ly met, pain is relived. Short term:The patient s pain scale decrease d 10/10 to 5/10Long term:The patient s pain diminish ed and performe d activiti es like side movement s and leg bending

Subjective:

Nasakit Ditoy nga banda as Verbalized by the patient evidenced by arm pointing at epigastric region.

After 8 hours of nursing intervent ions the patients pain will be relieved. Short term:Afte r 4 hours of nursing intervent ions, the patients pain scale will decrease 10/10 to 5/10Long term:Afte r 1 day of nursing intervent ions, patients pain will diminish and perform activitie s like side movement and leg bending

Objective:

Conscious and Coheren t Weak in Appeara nce With intact and dry dressing over the incision site. Facial grimace when in pain With guarding behaviour With minimal vaginal discharges Able to perform ADL with assistance V/S taken as

Acute Pain NDx: Acut e pain secondary to surgical operation Due to surgical procedure done that needs a surgical incision there will be presence of trauma in the area that signals an actual tissue damage and inflammat ion, this damage will cause an inflammat ion of the nerves when the nerves

Enhances coping abilitie s Refocus es the attenti on that may help in coping process es. Will help the client in the coping process . To assist in muscle and general ized relaxat ion Promote s

Provide adequate rest periods Assist client to learn breathing techniques

follows: T: 36.7 P: 70 R: 25 BP: 110/80 Subjective: T he patient may verbalized:M y incision hurtsObjecti ve:The patient manifested irritability impaired physical mobility disturbed sleep pattern facial mask diaphoresis restlessness facial grimaces

are affected, there will be the presence of pain.

Collaborative : Provide for individual ized physical therapy or exercise 1. program that can 2. be continued by the client after discharge. 3. Administer analgesics as 4. indicated to maximal dosage as needed Establish 5. rapport Emphasize 6. ordered diet Monitor vital signs 7. Provide comfort measures Encourage deep breathing Provide safety measure Develop communication review procedures/ex pectations and tell client when treatment will hurt

1. 2. 3. 4. 5. 6. 7.

active, rather than passive , role and enhance s sense of control . To gain trust To encourage patient not to eat untolerate d food To obtain baseline data To satisfy the confinemen t of patient To inhibit pain To prevent from injury To alter pain and diminish emotional stress To reduce concern of unknown and associa ted muscle tension & To maintai n accepta ble level of pain.