MA. THERESA DJ.
YUMANG
BSN 4
PATIENT NAME: Patient X
AGE: 28 Y/O
CASE NO.: 201
DIAGNOSIS: Incomplete Abortion +/- 20 wks age of gestation G3P1
ASSESSMENT
Subjective Data:
“May sakit parin akong
nararamdaman” as verbalized
by the patient.
Objective Data:
 Pain Scale of 6 out of 10
(10 being the highest, 1
being the lowest)
 Facial grimace
 Expressive behavior
 Slowed movement
 VS as follows:
T = 36.1oC
PR = 90 bpm
RR = 20 bpm
BP = 110/80mmHg
JANUARY 29, 2020
MS. KATE GABRIDO
NURSING CARE PLAN
NURSING PLAN OF ACTION NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Acute pain related After 8 hours of Independent Client’s pain was relieved
to post operation. nursing intervention, and controlled.
the client’s pain is  Monitor skin color and  These are usually altered in
relieved and temperature acute pain.
controlled.  Demonstrate and encourage  Promote nonpharmacological
deep breathing exercises. pain management.
 Provide comfort measure (touch,  Promote nonpharmacological
repositioning every 2hrs) and pain management.
quiet / calm environment
 Encourage use of relaxation
techniques such as focused  Distract attention and reduce
breathing tension.
 Encourage diversional activities
(TV, cp)
 Encourage adequate rest  Distract attention and reduce
periods. tension.
 Monitor vital signs.  Prevent fatigue.
 These are usually altered in
acute pain.