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Subjective Data

1) The student, Kevean Kimi Lim, was on their 5th rotation in the surgery ward where they cared for a patient who had undergone resection of a Meckel's diverticulum. 2) The patient presented with acute pain following surgery, scoring their pain a 6 out of 10. Nursing interventions included pain medication, relaxation techniques, and monitoring the patient's pain level and response to treatment. 3) After 8 hours of nursing care, the patient reported a decreased pain level of 3 out of 10.

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Kevean Kimi Lim
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55 views1 page

Subjective Data

1) The student, Kevean Kimi Lim, was on their 5th rotation in the surgery ward where they cared for a patient who had undergone resection of a Meckel's diverticulum. 2) The patient presented with acute pain following surgery, scoring their pain a 6 out of 10. Nursing interventions included pain medication, relaxation techniques, and monitoring the patient's pain level and response to treatment. 3) After 8 hours of nursing care, the patient reported a decreased pain level of 3 out of 10.

Uploaded by

Kevean Kimi Lim
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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STUDENT NAME: LIM, KEVEAN KIMI D.

ROTATION: 5th Rotation AREA: Surgery Ward


YEAR LEVEL & SECTION: BSN III - JEAN PIAGET DATES: Oct. 20,21,26, 27,28 & Nov. 3 CLINICAL INSTRUCTOR: Artley A. Garcia, RN
BLEEDING MECKEL’S DIVERTICULUM S/P: SEQUENTIAL RESECTION OF MECKEL’S
FINAL DIAGNOSIS: PROCEDURE PERFORMED: DIVERTICULUM

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION


Subjective Data: Acute pain related to Short term: Independent: Short term:
“Adda pay lang sakit na toy physical injury, as After 8 hours of 1. Obtain client’s assessment of 1. To rule out the After 8 hours of nursing
sugat iti operasyon na” as evidenced by pain scale of nursing intervention, pain to include location, worsening of the intervention, the patient
verbalized by the mother. 6/10, facial grimacing, and the patient will be able characteristics, onset/duration, underlying was able to report a
guarding behavior. to verbalize the frequency, quality, intensity, and condition/development of decrease in pain. Pain
decrease in pain. Pain precipitating/aggravating complications. scale of 3/10, 10 as the
scale of 3/10, 10 as factors. Reassess each time highest.
the highest. pain occurs/is reported.
2. Instruct in/encourage use of 2. To distract attention and
relaxation techniques, such as reduce tension from pain.
focused breathing, imaging, 3. To perceive their pain
Objective Data: CDs/tapes/phone (e.g., “white” management as more
Pain scale: 6/10 noise, music, instructional). effective and more likely to
(+) Facial grimace 3. Ascertain client’s knowledge participate in therapy if
(+) Guarding behavior of and expectations about pain their expectations are
management. discussed.
4. Determine factors in client’s 4. To determine and
lifestyle (e.g., alcohol/other assess if it affects
drug use/abuse). responses to analgesics
and/or choice of
interventions for pain
Dependent: management.
5. Administered medications as 5. To treat the underlying
ordered. condition.

Collaborative: 6. To improve awareness


6. Assist with treatments for of one's own needs and
underlying medical conditions general well being.

Note: Do not exceed in one (1) page in making an NCP.

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