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

To maintain “acceptable” level of

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