CUES

NURSING DIAGNOSIS

SCIENTIFIC ANALYSIS

GOAL OF CARE

NURSING INTERVENTION
Independent: Assessed and determine patients location, duration, and intensity of pain using the pain scale. Instructed client to perform relaxation technique like deep breathing exercise.

RATIONALE

EVALUATION

Subjective: Masakit yong tahi sa tiyan ko. as verbalized by the patient. Acute Pain: Related to presence of post - op surgical incision secondary to salpingectomy.

Objectives: Pain scale of 6 with 10 as the highest and 0 as no pain. Guarding Behavior Facial grimaced Narrowed focus V/S BP: 90/60 PR: 86 RR: 28 Temp.:

The treatment of choice After 8 hrs. of for ectopic pregnancy is rendering holistic care surgical removal. to patient the patient Salpingectomy is the will express signs of removal of one or both of relief of pain as a woman's fallopian evidence by: tubes, the tubes through which an egg travels Pain scale of 0 -3 from the ovary to the from 6 with 10 as uterus. the highest and 0 Regional or general as no pain. anesthesia may be used. Able to interact Often a laparoscope (a with others. hollow tube with a light No facial grimace. on one end) is used in this type of operation, which means that the incision can be much smaller and the recovery time much shorter. In this procedure, the surgeon makes a small incision just beneath the navel. The surgeon inserts a short hollow tube into the abdomen and, if necessary, pumps in carbon dioxide gas in order to move intestines out of the way and better

Assessment of the pain experience is the first step in planning pain management strategies.

After 8 hours of rendering holistic care to patient, the patient expressed signs of relief of pain as evidenced by:

Pain scale of 0-3 from 8 with 10 as Techniques are used the highest and 0 to bring about a as no pain. state of physical and mental awareness able to interact of tranquility. The well with others goal of these techniques is to reduce tension, no facial grimace subsequently reducing pain.

view the organs. After a wider double tube is inserted on one side for the laparoscope, another small incision is made on the other side through which other instruments can be inserted. After the operation is completed, the tubes and instruments are withdrawn. The tiny incisions are sutured and there is very little scarring. Acute pain is usually of short duration and has identifiable, immediate onset, such as incisional pain after surgery. It is also regarded as having post-operative pain, which usually disappears as the wound heals. Source: Medical-Surgical Nursing By: Black & Hawks Volume 1 pages 446 & 845

Initiated diversional activities like nurseclient interactions.

These heightened ones concentration upon non painful stimuli to decrease ones awareness and experience of pain. Massage decreases muscle tension and can promote comfort. Some people deny the experience of pain when it is present. Attention to associated signs may help the nurse in evaluating pain.

Provided comfort measures like massage or back rubbing. Observed or monitored signs and symptoms associated with pain, such as BP, heart rate, temperature, color, and moisture of skin, restlessness, and ability to focus. Dependent: Administer pain reliever as prescribed by the physician.

To reduce pain.