CHINESE GENERAL HOSPITAL COLLEGE OF NURSING Nursing Care Plan Patients Name: E.S.

Age: 52 Diagnoses: Post Thoracotomy with Resection

ASSESSMENT

NURSING DIAGNOSIS

INFERENCE

GOAL

INTERVENTION

RATIONALE

EVALUATION

Subjective: Sumasakit ung hiwa ko sa likod. as verbalized by the client Objective: Facial grimace was noted Level of pain was 6 out of 10 Slowed movement On CBC, WBC is increases (18.6 )

Acute pain related to surgery.

Acute pain is described as an unpleasant sensory or emotional experience associate with actual or potential tissue damage or injury as lasting from seconds to six months.

Short-term: After 30 minutes of nursing intervention, the patient will be able to gain knowledge in relieving pain as evidenced by: expected outcome: 1. Enumerate 3 ways on how to relieve pain such as: Deep breathing exercises Proper positioning Adequate rest periods 2. Decrease level of pain from 6 to 2

1. Provide rapport with the patient

1.To gain trust and full cooperation during the pain alleviation periods

2. Monitor vital signs

2. Vital signs altered during acute pain

Short-term: After 30 minutes of nursing intervention, the patient will be able to gain knowledge in relieving pain as evidenced by: expected outcome: 3. Enumerate 3 ways on how to relieve pain such as: Deep breathing exercises Proper positioning Adequate rest periods 4. Decrease level of pain from 6 to 2

3. Provide a therapeutic environment 4. Encourage verbalization of feelings

3. To aid in alleviation of pain 4. To assist in evaluation

5. Encourage to do diversional activities 6. Encourage rest and sleep 7. Provide for individualized physical

5.To alleviate pain

6. To assess in alleviation of pain and to prevent fatigue. 7. Promotes active, not passive, role and

Long-term: After 8 hours of nursing care, the client will be able to: Express alleviation of pain from 6 to 0 Absence of facial grimace

therapy or exercise program that can be continued by the client after discharge.

enhances sense of control.

Long-term: After 8 hours of nursing care, the client will be able to: Express alleviation of pain from 6 to 0 Absence of facial grimace