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Nursing Care Plan

Cues Nursing Analysis Goal and Interventions Rationale Evaluation
Diagnosis Objectives

Subjective: Acute pain The client is Goal: After 12- The client’s pain
The client related to experiencing pain hours shift, the was lessened.
verbalized post-op due to the client’s pain will
-“masakit surgical episiotomy done be lessened.
talaga yung incision to her after the CS
tahi ko, operation. Objective: DEVELOPMENTAL
nahihiripan Pain is a typical :
ako sensory > After 5 Pain is a subjective The client was
gumalaw” experience that minutes, the Perform a experience and must able to verbalize
-“hindi ko may be described client will comprehensive be described by the to characterize
magawa as the unpleasant verbalize the assessment of client in order to plan and locate the
mapa dede awareness of a characteristic pain to include effective treatment. pain.
anak ko noxious stimulus and location of location,
magisa dahil or bodily harm. pain. characteristics,
sa sakit” Individuals onset, duration,
-“siguro experience pain frequency,
nasa ‘6’ (10 by various daily quality, intensity
highest) ang hurts and aches, or severity, and
sakit niya.” and occasionally precipitating
-“hindi through more factors of pain.
talaga ako serious injuries or
makagalaw illnesses. DEVELOPMENTAL The use of The client was
dahil sa tahi, : noninvasive pain able to perform
nakakinis (http://en.wikipedia. > After 10 relief measures can deep breathing
nga eh” org minutes client Teach the use of increase the release exercise.
/wiki/pain) will be able to non- of endorphins and
Objective: perform pain pharmacologic enhance the
-presence of management: techniques: therapeutic effects of
grimace -deep breathing -deep breathing pain relief
-on guarding technique technique medications.
position
during the
interview
-pale The client was
-RR: 24 able to take her
breath/min FACILITATIVE: Each client has a due med.
> On the given right to expect
time, administer Provide optimal maximum pain relief.
pain reliever to pain relief with Optimal pain relief
the client. doctor’s using analgesics
prescribed includes determining
analgesics. the preferred route,
drug, dosage, and
frequency for each
individual.
Medications ordered
on a prn basis should
be offered to the
client at the interval
when the next dose
is available.
The client’s vital
signs were
monitored.
> After every 4 SUPPLEMENTAL:
hours, the Assessment of vital
client’s vital Monitor client’s signs is an important
signs will be vital signs component of the
monitored. including: blood physical therapy Efficiency
pressure, examination and The time,
respiratory rate, should be included in materials, and
pulse rate and the examination of human
temperature. all patients. resources were
Knowledge of vital used
signs allows the economically
therapist to
understand a
patient's physiologic
status and is helpful
in determining Adequacy
appropriate goals. The numbers of
interventions
were sufficient.
Appropriateness
The
interventions
were suitable to
the client’s
situation.

Acceptability
The
interventions,
setting, and
timetable were
realistic to the
client’s
situation.