Vasquez, Mari Sheanne M.

October 31, 2022

BSN 4-A Ms. Madonna C. Beler

Nursing Problem: Acute pain related to three days post-op wound closure as evidenced by impaired physical mobility
Nursing Care Plan

NURSING RELATED DRUG RELATED LAB SHORT TERM NURSING EVALUATION/

DIAGNOSIS THERAPEUTICS DIAGNOSTICS GOAL INTERVENTIONS OUTCOME

Acute pain related 1. Ketorolac None After the end of my ● Provide Goal partially met.
to three days 30mg (IV) Q8 shift of nursing rapport with Patient was able to
post-op wound RTC x 6 dose interventions, the the patient gain knowledge in
closure as 2. Celecoxib patient will be able ● Provide a relieving pain as
evidenced by 100mg cap to gain knowledge therapeutic
evidenced by
impaired physical Q8 RTC x 3 in relieving pain as environment
mobility days evidenced by ● Perform pain expected outcome:
3. Tramadol expected outcome: assessment ● Decreased
25mg (IV) Q4 ● Decreased ● Encourage level of pain
PRN for level of pain verbalization ● Use of
breakthrough ● Use of of feelings relaxation
pain relaxation ● Provide skills
skills measures like ● Deep
● Deep change in breathing
breathing position to exercises
exercises relieve pain ● Proper
● Proper before it positioning
positioning becomes ● Demonstrates
● Demonstrat severe measure to
es measure ● Provide increase
mobility
 to increase pharmacologic ● Adequate rest
mobility pain periods
● Adequate management
rest periods as ordered
● Encourage
patient to do
post-operative
exercises
● Promote and
facilitate early
ambulation
when possible.
Aid with each
initial change:
dangling legs,
sitting in chair,
and
ambulation.