LIST OF IDENTIFIED PROBLEMS
1. Acute pain related to tissue trauma secondary to surgical procedure
2. Powerlessness related to early loss of pregnancy secondary to ectopic pregnancy.
3. Rick for infection related to related to breakdown of the body's first line of defense.
4. Impaired skin integrity related to tissue trauma secondary to surgical procedure
5. Activity intolerance related to body weakness. PRIORITIZATION OF PROBLEMS
Nursing Diagnosis Rationale
Acute pain related to tissue trauma secondary to surgical procedure
It is a high priority since my patient verbalized a 7/10, 10 as most severe. Other problems below are underlying problems caused by pain.
Impaired skin integrity related to tissue trauma secondary to surgical procedure
This is the second because following “ABC” this falls down in Circulation. But although there may be an alteration in the patient’s circulation, it is not that much.
Activity intolerance related to body weakness.
This is the third since this falls in “Basic needs” of Maslow’s hierarchy of needs. It is because physical activity can be accomplished with intact and functioning neuromuscular and skeletal systems.
Powerlessness related to early loss of pregnancy secondary to ectopic pregnancy.
This is the fourth since this belongs to “Love and belongingness” of Maslow’s Hierarchy of needs. The mother lost a child to be cared and loved.
Rick for infection related to related to breakdown of the body's first line of defense.
This is the fifth since this is just a risk and we can do intervention to prevent this from happening.
NURSING CARE PLAN
Assessment:
Problem: Postoperative Pain
Subjective Data:
“ Nu agpagpagna ak ket nasakit jay sugat ko pati metlang nu agtugtugaw ak”
Rated pain as 7/ 10, 10 being most severe, characterized as dull, localized over wound, intermittent and aggravated by movement. Obejective Data:
T: 37.1 C BP: 100/ 60 PR: 113 bpm RR: 28 bpm
With good skin turgor and 1-2 seconds capillary refill With an abdominal binder in place
Nursing Diagnosis: Acute pain related to tissue trauma secondary to post surgical procedure.
Explanation of the Problem:
Ectopic pregnancy is a possible cause of severe abdominal pain in the first trimester. This happens when the egg implants inside the fallopian tubes or elsewhere outside the uterus. The first sign a woman may notice is vaginal bleeding followed by lower abdominal pain that intensifies with time. Vomiting, dizziness, and shoulder pain could also occur. It is very important for a woman experiencing these symptoms to get medical attention as soon as possible wherein there will be a need for eplore laparotomy and salpingectomy. The abdominal pain associated post status salphingectomy may be described as cramping or severe continuous pain. Pain is a typical sensory experience that may be described at the unpleasant awareness of a noxious stimulus or bodily harm.
Reference: Med-Surg by BRUNNER SUDDARTH pages 1404 Goals/ Objectives:
Short Term Objective:
After 8 hours of nursing intervention, the patient will be able to rate pain from 7/ 10 to 2/10, 10 being most severe.
Long Term Objective:
After 3 days of nursing intervention, the patient will be able to verbalize absence of pain.
Interventions Rationale Dx.
Assessed vital signs and dressings
Assessed for pain using PQRST.
Tx.
Independent:
Provided additional comfort measures like back rub
Communicate with patient Dependent:
Increase in BP and CR indicates patient is in pain. Moistened dressings are favorable site for microorganisms to culture and if there would be inflammation, it would cause pain at the incision site.
Pain is a subjective experience; experience of pain can be answered through verbalization.
This can be explained by Gate Theory wherein the transmission painful impulses to the level of consciousness are being inhibited by the closure of the gate blocking these sensations.
Attention can be diverted, letting the focus on other stimulus.
Intake of pain relievers as per doctor’s order and advise
Celecoxib(Celebrex) 200mg 1 tab BID
Classification: Analgesic MOA: inhibits cyclo-oxgenase 2 which is responsible for prostaglandin synthesis; reduces inflammation and relieves pain.
Nursing Consideration: Take in preferably with food and full glass of water to prevent GI upset.
Edx.
Encouraged use of relaxation technique like deep breathing exercises
Recommended planned or progressive exercise
NSAID activity includes modulation of T-cell function, inhibition and inflammatory cell chemotaxis, decreased release of superoxide, radicals or increased scavenging of these compounds at inflammatory sites.
There would be a better perfusion / circulation of blood providing adequate oxygen to the traumatized tissue therefore inhibiting pain to occur.
Prevents undue strain on operative site. Promotes return of normal function and enhances feelings of general well being. It relieves pain by
Encouraged enough rest and sleep
Noted to avoid weight bearing until allowed
diverting her attention not focusing on her postoperative pain.
Pain can be prevented by reducing basal metabolic rate and allowing oxygen and nutrients to be utilized for tissue growth and regeneration to prevent inflammation of the wound which causes pain.
Avoid straining of the sutures which may possibly cause pain, activities that may extend the cut must then be avoided.
References:
Med-Surg by Brunner Suddarth pages 1404 – 1406
Maternal and Child Health Nursing by Pillitteri pages 559 - 560 Evaluation:
Objective partially met as evidenced by the verbalization of patient rating pain as 3/ 10, 10 being most severe.
