CUES (defining characteristics of Nrsg Dx) Subjective: “Masakit yung tahi ko lalo na kapag gumagalaw ako†Objective: >Facial Grimace with pain scale of 4 >Protective Gesture to avoid pai…Full description
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AS SE SE SS SS ME ME NT NT
S> “Aray!!! Masakit po!.” as verbalized by the client.
O>Facial grimace >crying >muscle guarding in the genital area >Surgical incision in the penis >Pain scale of 5/5
N UR UR SI SI N NG G
SCIENTIFIC
DIAGNOSIS
EXPLANATION
Acute pain related to post surgery (Circumcision) as evidenced by facial grimace and surgical incision in the penis.
Mechanical, thermal or chemical stimuli.
Nociceptors
Afferent Nerves
PL AN AN NI NI N NG G
I MP MP LE LE ME MEN TAT IO IO N
Discharge Outcome: Outcome : After 1 month of nursing interventions, the client will be free from experiencing pain in the genital area.
Independent: ♥ Encourage patient to verbalize about pain.
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End terminals
unmyelinated C fibers and myelinated-A delta fibers
spinal cord
brain cortex
Pain
S CI CI EN EN TI TI FI FI C
EVALUATION
RATIONALE
Short Term Outcome: Outcome : After 3 hours of nursing interventions: 1. the the clie client nt will state 3 ways of relieving pain such as imagery, application of hot and cold compress and
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Provide comfort measures such as deep breathing exercises like yoga and meditation. Encourage diversional activities (TV/radio, socialization with others, imagery) Provide application of hot and cold compress.
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Provide therapeutic
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Promotes cooperation from the client. (Fundamentals of Nursing by Taylor 5th e. p.1216) This calms and soothes the patient. (Fundamentals of Nursing by Taylor 5th e. p.1216)
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To divert attention from pain. (Fundamentals of Nursing by Taylor 5th e. p.1216)
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To relieve pain in the muscle area. Maternal and Child Health Nursing 5th e. by Pilliteri page 547) To promote feeling of comfort.
Outcome Achieved. Client stated 3 ways of relieving pain such as imagery, application of hot and cold compress and therapeutic touch.
REFERENCE: Maternal and Child Health Nursing 5 th e. by Pilliteri page 545
therapeutic touch. 2. the the clie client nt’s ’s pain scale will decrease from 5/5 to 3/5.
touch.
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Increase intake of Vitamin C.
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Monitor Vital signs.
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Collaborative: ♥ Administer Mefenamic Acid and Toradol (analgesic) as ordered.
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(Maternal and Child Health Nursing 5th e. by Pilliteri page 547) To promote healing of wound. (Nutrition and Diet Therapy by Peckenpaugh page 328) An information baseline comparison from previous data. (Manual of Nursing Procedures Vol. I by Locquiao, Cruz, Arguelles and Lontoc page 122) To comply with the physician’s order. (Manual of Nursing Procedures Vol. II Locquiao, Manalastas, Mejilla and Merin. page 3)
