IX.

NURSING CARE PLAN

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION
S> “Masaki tang Acute pain elated Due to surgical After 4 hours of After 4 hours of
opera ko” as to tissue trauma procedure done nursing  Monitor vital  To obtain nursing
verbalized by the secondary to that needs a interventions the signs. baseline interventions the
patient. abdominal surgical incision patient’s pain scale data. patient’s pain
surgery. there will be will decrease 7/10 to scale decreased
O> conscious and presence of 5/10.  Divertional  To divert the 7/10 to 5/10.
coherent trauma in the activities like patient’s
 Pallor area that signals story telling attention.
 Facial an actual tissue and asking
grimace damage and questions.
 Irritability inflammation,
 Weakness this damage will  Provide  Promote
 Scale of pain cause an comfort relaxation
= 7/10 inflammation of measure and may
the nerves when (deep enhance
the nerves are breathing client’s
affected, there exercise, coping
will be the comfortable abilities by
presence of position) refocusing
pain. attention.

 Encourage  To prevent
adequate fatigue.
rest.
 Identify ways  To promotes
of minimizing comfort
pain. (good
body
mechanics,
using firm
mattress)

 Work with  To prevent

client. pain.

 Administer
analgesic as  To main
indicated to acceptable
maximum level of pain.
dosage, as
needed.
Generic name:  Antibiotic  Inhibits  UTI caused by  Pseudo-  Contraindicated  Give oral  Increased
Cefuroxime synthesis of E. Coli membranou with allergy to drug with bleeding
bacterial  Uncomplicated s colitis cephalos- food to effects with
Brand name: cell wall, gonorrhea  Nausea phorins or decrease GI oral anti-
Ceftin causing cell  Lower  Vomiting penicillin. upset and coagulants
death. respiratory  Anorexia  Use cautiously enhance  Increased
Dose: infection  Abdominal with lactation, absorption. nephrotoxicity
750mg caused by S. pain pregnancy.  Discontinue with amino
Pnuemoniae  Headache if hyper- glycoside
Frequency:  Genital sensitivity  Possibility of
 Dizziness
q8° infection occurs. false result on
 Lethargy
 Monitor VS, test of urine
urine output glucose using
and Benedict’s
laboratory solution.
report.
Record
abnormal
findings.
 Refrigerate
oral
suspension.
Generic name:  Antibiotic  Inhibits  UTI caused by  Pseudo-  Contraindicated  Give oral  Increased
Cefuroxime synthesis of E. Coli membranou with allergy to drug with bleeding
bacterial  Uncomplicated s colitis cephalos- food to effects with
Brand name: cell wall, gonorrhea  Nausea phorins or decrease GI oral anti-
Ceftin causing cell  Lower  Vomiting penicillin. upset and coagulants
death. respiratory  Anorexia  Use cautiously enhance  Increased
Dose: infection  Abdominal with lactation, absorption. nephrotoxicity
750mg caused by S. pain pregnancy.  Discontinue with amino
Pnuemoniae  Headache if hyper- glycoside
Frequency:  Genital sensitivity  Possibility of
 Dizziness
q8° infection occurs. false result on
 Lethargy
 Monitor VS, test of urine
urine output glucose using
and Benedict’s
laboratory solution.
report.
Record
abnormal
findings.
 Refrigerate
oral
suspension.
 IX. NURSING CARE PROCESS

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION
S> “Masaki tang Acute pain elated Due to surgical After 4 hours of After 4 hours of
opera ko” as to tissue trauma procedure done nursing  Monitored vital  To obtain nursing
verbalized by the secondary to that needs a interventions the signs. baseline interventions the
patient. abdominal surgical incision patient’s pain scale data. patient’s pain
surgery. there will be will decrease 7/10 scale decreased
O> conscious and presence of to 5/10.  Divertional  To divert the 7/10 to 5/10.
coherent trauma in the activities done patient’s
 Pallor area that signals like story telling attention.
 Facial an actual tissue and asking
grimace damage and questions.
 Irritability inflammation,
 Weakness this damage will  Provided  Promote
 Scale of pain cause an comfort relaxation
= 7/10 inflammation of measure (deep and may
the nerves when breathing enhance
the nerves are exercise, client’s
affected, there comfortable coping
will be the position) abilities by
presence of refocusing
pain. attention.

 Encouraged  To prevent
adequate rest. fatigue.
 Identified ways  To promotes
of minimizing comfort
pain. (good
body
mechanics,
using firm
mattress)

 Worked with  To prevent

client. pain.

 Administered
analgesic as  To main
indicated to acceptable
maximum level of pain.
dosage, as
needed.