Karen Elizabeth B. ValdezRLE 4.10.2

CUES AND CLUES

NURSING DIAGNOSIS

ANALYSIS GOAL AND OBJECTIVES

IMPLEMENTATION RATIONALE EVALUATION

Patient is nonverbal but able to express feeling of pain through the ff:1. Guarding

behavior2. Facial

grimace Upon breathing

patient holds the surgical site and complains pain

Pain increased when coughing

Surgical dressing is dry and intact

RR=25

Acute pain related to post-surgical incision on the chest area

Nociceptors are free nerve endings that are widely distributed throughout the body. Chemically mediated activation of nociceptors can be initiated by cell wall destruction as a result of events such as tissue injury or inflammation. Since there is injury within the CTT site, activation of chemicals such as bradykinin, prostaglandin, histamine, serotonin, leukotrienes and nerve growth factor are released. With the release of these chemicals, pain is produced.

After 7 hours of nursing interventions, patient’s pain and discomfort will diminish and will demonstrate nonpharmacologic methods that provide relief of pain

1. Encourage adequate rest periods

2. Maintain care postoperatively in positioning the patient: Place patient in semi-Fowler’s position

3. Provide proper ventilation, change soiled linens and remove unnecessary materials in bed

4. Encourage diversional activities

5. Perform cluster care

6. Assess incision area every 8 hours for redness, heat, induration, swelling, separation and drainage

1. To decrease oxygen demand and provide more strength

2. Semi-fowlers position permits residual air in the pleural space to rise to upper portion of pleural space and be removed via the upper chest catheter

3. To promote maximum ventilation and proper breathing as well as relaxation

4. To divert attention from pain.

5. To provide rest periods

6. These signs indicate possible infection

After 7 hours of nursing interventions,1. Patient

avoids vigorous movements and rests adequately

2. Patient’s pain is still aggravated when coughing

3. No signs of incisional infection evident