Assessment

Subjective Masakit yung sap pwet ko verbalized by the client Gusto ko ng maoprehan As verbalized by the client Objective Facial Grimace Guarding Behavior Pain Scale of 6 out of 10.

Nursing Diagnosis
Acute Pain related to disease process as manifested by pain scale 6 out of 10.

Analysis
Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. (NANDA DOENGES 2011)

Goal and Objectives

After 8 hrs of nursing intervention the client will able to report reduction of pain.

Nursing Rationale Intervention

Evaluation

Objectives After 1 hour of nursing intervention the client will be able to verbalize feelings and concern about pain. Assess clients condition with regards to pain Obtain clients assessment of pain to include location, frequency duration and intensity. Help determine possibility of underlying condition To rule out worsening of the condition Was the client able to verbalize feelings and concern about pain? Yes? No? How?

Accept clients description of pain

Pain is subjective that cannot be felt by others Indicate pain

Observe nonverbal pain behavior To promote comfort and to divert attention

After 2 hours of nursing intervention the client will be able to demonstrate non pharmacological methods the provide relief.

Promote comfort measures Reposition the client Provide calm environment

Prevent stimuli that may cause pain

Was the client able to demonstrate non pharmacological methods that provide relief? Yes? No? How?

Instruct use of To promote relaxation comfort techniques

Encourage to do breathing exercise After 2hours of nursing intervention the client will be able to follow prescribed pharmacological management Explain the client the effects of the medication and why is it needed? Administer tramadol as ordered by the physician

To release tension

For better understanding of the medications

Was the client able to follow prescribed pharmacological management? Yes? No? How?

For reduction of pain.

Learning Objective
After 4 hours of nurse-patient interaction the client will be able to: State the uses of pain

Learning Content

Method and Strategy

Lectures and Demonstration Pen and Manila Paper

Resources

Day Time and Venue

January 18, 2013 4-8pm

Evaluation

Time and effort Video

Utilize different non pharmacological pain management Appreciate teaching rendered

Nonpharmacological or natural therapies are things you can do or think about that help decrease your pain. These therapies do not involve taking medicines, but work along with your medicines. The different nonpharmacological pain management.Breathing exercises, Music therapy,

Massage, Distraction, Heat and Cold, Laughter. How to do deep breathing exercises.- Sit up straight. (Do not arch your back) First exhale completely through your mouth. Place your hands on your stomach, just above your waist. Breathe in slowly through your nose, pushing your hands out with your stomach. This ensures that you are breathing deeply.

Imagine that you are filling your body with air from the bottom up. Hold your breath to a count of two to five, or whatever you can handle. It is easier to hold your breath if you continue to hold out your stomach. Slowly and steadily breathe out through your mouth, feeling your hands move back in as you slowly contract your stomach, until most of the air is out. Exhalations a little longer than inhalation.

Learning Objective
After 4 hours of nurse patient interaction the client will be able to: Understand the need of colostomy

Learning Content

Method and Strategy

Lecture and Demonstration

Resources
Video Pen and Paper

Day Time and Venue

January 18,2013 4pm to 8pm

Evaluation

Importance of colostomy care

Ang mga general surgeon or colorectal surgeon ang siyang gumagawa ng procedure upang maibsan ang tumor o cancer o kung anumang sakit na tumama sa colon. Ang opening ay naging daan para magkaroon ng pangalawang buhay.

Demonstrate colostomy care

iempty ang colostomy bag para hindi mapuno at matapon tanggalin ang colostomy bag ng mabuti at maingat linisan at tuyuin ang balat sa may stoma. Tuyuin ito ng mabuti.
Dapat ito ay panatilihing tuyo

Palitan ang nakadikit sa may stoma ng bago at palitan ng bagong colostomy bag