Patient: J.S.
Admitting Diagnosis: Post-Debridement with Jackson Pratt Drain
Assessment Nursing Diagnosis Rationale Desired Outcomes Nursing Interventions Justifications Evaluation
Actual/Abnormal Acute pain related Multiple hack After 3 hours of After 3 hours of nursing
cues to presence of wound at the nursing interventions, the patient was
Patient complained, postoperative temporoparietal interventions, the able to:
“Gasakit ang ulo surgical incision as and neck area patient will be able
ko” evidenced by due to to:
(+) Guarding verbal report of mechanical 1.)Report pain is 1.1 Assess for referred 1.1 To help 1.) Goal met. Verbalized,
behavior of putting pain at head part, trauma relieved/ pain, as appropriate determine “waay naman gasakit kag
his arm on his head guarding behavior, controlled. possibility of gahubag akon ulo”. No
part and facial mask underlying signs of inflammation on
Undergone condition or the surgical wound such
Has a facial [beaten look].
surgical organ. as presence of erythema
expression like that
Definition: intervention of 1.2 Obtain client 1.2 To rule out and swelling.
of a beaten look
debridement assessment to pain worsening of
face Unpleasant sensory
with Jackson including location, underlying
Patient seen and emotional
Pratt drain characteristics, condition/
changing position experience arising
onset/duration, intensity, development of
every now and then from actual/
precipitating and complications.
Pain scale of 6 potential tissue
Inflammation of aggravating factors.
damage or
surgical wound Reassess each time pain
Risk/Risk Factors described in terms
as part of healing occurs/is reported.
Presence of of such damage
process /
Jackson Pratt drain (International
wearing off of 1.3 Monitor skin color/ 1.3 Which are
in the head Association for the
anesthetic temperature and vital usually altered
Strengths study of Pain);
substances signs in acute pain
sudden/slow onset
Strong family
of any intensity
support
from mild to severe
Good compliance with an anticipated Acute pain 2.)Follow 2.1 Administer analgesics, 2.1 To maintain 2.) Goal met. Complied in
to treatment and or predictable end related to prescribed Paracetamol and acceptable level of taking medications on
medications and a duration of postoperative pharmacological Celecoxib, as indicated to pain. Notify time such as Paracetamol
less than 6 months. surgical incision regimen. maximum dosage as physician if 500 mg 1 tab PO PRN
needed. regimen is and Celecoxib 200 mg 1
Source: Source: inadequate to meet cap OD for pain relief
Doenges, M.E, et. Medical- pain control goal.
Al. Nurse’s Pocket Surgical Book
Guide Edition 11. 2.2 evaluate/ document 2.2 increasing/
Edition 16 by
F.A. Davis client’s response to decreasing dosage,
Williams and
Company. analgesia, and assist in stepped program
Wilkins. transitioning/ altering drug helps in self-
Philadelphia,
regimen, based on management of
Pennsylvania.
individual needs. pain.
2008.
3.)Demonstrate use 3.1 provide comfort 3.1 to promote non- 3.) Goal met. Demonstrated
of relaxation measures (e.g., touch, pharmacological use of relaxation skills
skill and repositioning, nurse’s pain management and diversional activities
diversional presence), quite by elevating his injured
activities as environment and calm part (head) to 30 degree
indicated for activities. angle, practice calm
individual activities (moving slowly
situations. 3.2 instruct in/encourage 3.2 to distract when getting up on bed
use of relaxation attention and and turning from side to
techniques such as focused reduce tension side) and having adequate
breathing, imaging. rest periods such as
taking a nap.
3.3 encourage having 3.3 to prevent
adequate rest periods. fatigue
