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NURSING CARE PLAN

Mrs. Patao
OB WARD, GSGH

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION


Subjective Acute Pain r/t After 8 hours of nursing Independent Goal met. Client
surgical trauma intervention, client will: Determine characteristics and Client may not verbally report pain reported that pain have
“Agsakit sakit ti as evidenced location of and discomfort directly. Comparing been relieved and did
sugat ko kasla by: discomfort. specific characteristics of pain aids not manifest further
lang Identify and use Note verbal and nonverbal cues, in differentiating postoperative pain evidence of pain.
agpitikpitik,” as Reports of appropriate such as from developing complications Followed prescribed
verbalized by incisional pain interventions to grimacing, rigidity, and guarding (e.g., ileus, bladder retention or pharmacological
the client Guarding manage or pain from developing infection, wound) regimen. Demonstrate
behavior pain/discomfort. complications use of relaxation skills
Objective Facial mask of restricted movement. and diversional
Observed pain. Verbalize lessening of Promotes problem solving, helps activities, as indicated,
evidence of pain 5 out of 10 pain level of pain. reduce pain associated with anxiety for individual situation.
scale Provide information and and fear of the unknown,
Facial mask; Appear relaxed, able to anticipatory guidance regarding and provides sense of control.
eyes lack luster, sleep/rest causes of discomfort and
fixed appropriately. appropriate interventions.
movement, In many clients vital signs are
grimace usually altered in acute pain.

Restless and Monitor skin color/temperature


sighing and vital signs (e.g., heart rate,
blood pressure, respirations) Relaxes muscles, and redirects
Pain scale: 5 out attention away from painful
of 10 sensations. Promotes comfort, and
v/s: Reposition client, reduce noxious reduces unpleasant distractions,
T- 37.5 stimuli, and Relaxes muscles, and enhancing sense of well-being.
PR- 60 redirects attention away
beats/min offer comfort measures, e.g., back
RR- 19 rubs. Encourage from painful
breaths/min sensations. Promotes comfort,
BP- 110/80mHg and
use of breathing and relaxation
techniques and reduces
unpleasant distractions,
CAMPOL, R-J
BSN II CADM
SPCIS
NURSING CARE PLAN
Mrs. Patao
OB WARD, GSGH

enhancing sense
distraction (stimulation of
cutaneous tissue). of well-being Deep breathing enhances
Encourage presence and respiratory effort. Splinting reduces
participation of partner as strain and stretching of incisional
appropriate. area and lessens pain and
discomfort associated with
Initiate deep-breathing exercises, movement of abdominal muscles.
incentive spirometry, and Coughing is indicated when
coughing using splinting secretions or rhonchi are
procedures, as appropriate, 30 auscultated.
min after administration of
analgesics.

To maintain “acceptable” level of


pain. Notify physician if regimen is
Dependent inadequate to meet pain control
goal.
Administer analgesics, as
indicated, to maximum dosage, as
needed.
PCA using meperidine or morphine
may be used to provide rapid pain
relief without excessive side
effects/oversedation. Enhances
Demonstrate/monitor use of self- sense of control, general well-being,
administration/patient-controlled and independence.
analgesia (PCA) for management
of severe, persistent pain.
Increasing/decreasing dosage,
stepped program (switching from
injection to oral route, increased
CAMPOL, R-J
BSN II CADM
SPCIS
NURSING CARE PLAN
Mrs. Patao
OB WARD, GSGH

Evaluate/document client’s time span as pain lessens) helps in


response to analgesia, and assist self-management of pain.
in transitioning/altering drug
regimen, based on individual
needs.

CAMPOL, R-J
BSN II CADM
SPCIS