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NURSING CARE PLAN # 1

ASSESSMENT DIAGNOSIS

(NANDA-BASED)

PLANNING IMPLEMENTATION RATIONALE

(cite sources)

EVALUAT

(ACTUA

Subjective cue!

- Dili na kaayo

sakit,

verbalized by

the patient.- Pain Scale of

6 out of 10

Objective cue!

- ncision on the

lo!er

abdo"en- #uardin$

%ehavior- &acial $ri"ace- Positionin$ to

avoid pain

'cute Pain

r(t to )issue

)rau"a Secondary

to Status Post

)'*%S+ )otal

'bdo"inal

*ysterecto"y

%ilateral Salphin$o

+ophorecto"y-

S"$t te$%!

'fter hours of

nursin$

interventions/

1. the client !ill

state !ays

of relievin$

pain such as

i"a$ery,

application of

hot and cold

co"press and

therapeutic

touch. the clients

pain scale !ill

decrease

fro" 2 to .

I&'ee&'e&t

1. nstruct client to report

any

i"prove"ent(e3acerbatio

n in pain e3perience.. 4ncoura$e and assist

client to do deep

breathin$ e3ercises.. 4ncoura$e ade5uate

periods of rest and sleep,

includin$ uninterruptedperiods of sufficient

duration, "eetin$ co"fort

needs, li"itin$( avoidin$

use of caffeine( alcohol

and "edications affectin$

47 sleep. 4ncoura$e

5uiet, restful at"osphere.

2. Discuss !ith relatives thei"portance of early

detection and reportin$ of

chan$es in condition or

1. 8nrelieved pain can create

other proble"s such as an$er,

an3iety, i""obility, respiratory

proble"s, and delay in healin$.. Deep breathin$ for rela3ation is

easy to learn and contributes to

pain relief and(or reduction by

reducin$ "uscle tension and

an3iety.

3. )o prevent fati$ue.

4. Pro"otes early detection of

developin$ co"plications.

5. t "ay be possible to teach

clients a co"bination of these

techni5ues to "a3i"ize their

opportunities for self9control

over "anifestations of pain.

6. )o pro"ote healin$ of !ound.:. 'n infor"ation baseline

co"parison fro" previous data.;.

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L& te$%!

't the end of 2

hours, patient !ill

rate pain as 0 out of

10

any unusual physical

disco"forts( chan$es.

=. )each the client and

si$nificant others about

the nonphar"acolo$ic

!ays to lessen pain.

6. ncrease intake

of >ita"in ?

:. 7onitor >ital si$ns

C**+b$+tive,Dee&'e&t!

;. 'd"inister "edications

particularly anal$esics-

as prescribed.

acceptable level of pain.