Ncp Incarcerated Inguinal Hernia

Javier, Janna Gale G. NURSING CARE PLAN Incarcerated Inguinal Hernia (IIH)

Cues

Nursing Diagnosis

Subjective

Acute pain related to surgical “I feel less pain in procedure as surgical incision on manifested by the right side but not patient radiating to left side. verbalization (Medyo makirot pa rin po ung tahi ko sa kanan pero wala namang sakit sa bandang kaliwa ng sugat.)”, as verbalized by the patient. Patient’s daughter mentioned that his father cannot move freely without pain and needs assistance to get down from the bed. Objective Patient states that his abdominal pain level is a 4 on a 0 – 10 point pain rating scale. Patient’s pressure

blood changes

Rationale

Pain is a highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors may be experienced by the patient.

Goal

Nursing Intervention

Short Term

Independent Functions

Patient will verbalize pain less than 4 or 0, on a 0-10 pain rating scale by end of 210pm shift.

Assess the patient’s pain by using the 10 point pain rating scale q4 hrs or PRN during the 2-10pm shift.

After performing the nursing interventions, patient will Without adequate experience relief. pain management, it may interfere with patient’s ability to perform ADL’s, progress towards healing, and patient’s participation in treatment plan.

Have the patient splint the incision site with hand or pillow when coughing to lessen pain and protect site from increased intraabdominal pressure. Before any activities, treat pain.

Explaining and teaching nonpharmacologic pain relief methods, such as breathing exercises, music therapy, distraction and

Rationale of the Nursing Intervention

Evaluation Goals partially met.

Single- item ratings of pain intensity are Continue valid and reliable as interventions as measures of pain listed. intensity. Continue to The client’s report of assess pain using pain is the single most the 10 point pain reliable indicator of scale q4 hrs or pain. PRN. (Ackley & Ladwig, 2008, p. 604-605). Continue to provide pain Splinting and proper control and treat positing reduce the as needed. stress on the incision area. The patient reported relief from a 4 to 2 on a 0 – 10 pain Pain limits mobility rating scale after and is often the 2 – 10 shift. exacerbated by movement. (Ackley & Ladwig, 2008, p 552). These relaxation techniques decrease oxygen consumption, respiratory rate, heart rate, and muscle

from normal baseline data but heart and respiration rate remain regular and normal. Patient’s midline abdominal incision appears dry and intact. Patient show grimaces occasionally during any kind of motion or movement of his body. Patient’s feet are twitching when incision is being cleansed.

progressive relaxation tension, which before, after, and if possible interrupt the cycle of during painful activities. pain–anxiety–muscle tension. Reduce or eliminate factors that precipitate or increase patient’s pain experience (e.g., fear, fatigue, and lack of knowledge)

Personal factors can influence pain and pain tolerance. Factors that may be precipitating or augmenting pain should be reduced or eliminated to enhance the pain management program.

Keep side rails up and bed in low position.

This promotes a safe environment.

Frequent repositioning of To prevent back pain the patient when lying in and bedsores at the bed. back, sacrum and buttocks.