NURSING PROCESS CARE PLAN FORMAT

PATIENT'S INITIALS: M.M.

DATES OF CARE: 03-25-2010

ASSESSMENT ANALYSIS PLANNING IMPLEMENTATION EVALUATION

PATIENT GOALS/ SCIENTIFIC
SUPPORTIVE NURSING OUTCOME NURSING PRINCIPLES/ OBSERVATIONS/
DATA DIAGNOSIS CRITERIA ACTIONS RATIONALE CONCLUSIONS

S: “Percocet did not Acute Pain r/t surgical STG: Independent: STG met AEB pain
work at all, not sure if procedure. Patient will verbalize 1. Teach the 1. This level did not exceed
Vicodin is working reduction of pain AEB effectivenes supports 4/10 for entire shift.
either.” rating pain <5/10 by incision and
s of abdominal Will discontinue goal
EOS. abdominal muscles, as patient is
O: Frowning, holding splinting reducing discharged.
breath, and tightly during discomfort.
closing eyes with movement.
movement. LTG: LTG met AEB patient
Patient will perform 2. Assess pain 2. JCAHO showered, dressed, and
48 F self- care activities like level and mandates packed her belongings
TAH/ BSO, Burch showering and frequent,
dressing without effectivenes regular without assistance or
procedure on s of verbalizing pain. Pain
assistance and pain assessment
3/22/2010 for <5/10 by discharge. medicine and was 2/10 at time of
Endometriosis, every 3 treatment of discharge.
Fibroids, and Ovarian pain.
hours .
Cysts.
This is post op day 3.
Collaborative: 1. JCAHO
mandates
Patient discharged frequent,
1. Administer
today. regular
Vicoprofen
assessment
Low midline 7.5/200mg
and
incision(Durabond) 1-2 every 6
with JP drain intact on hrs or 1 treatment of
left side of incision. every 3 hrs pain.
Voiding- BRP PRN pain
JP output 75cc in 8 hrs as ordered

T 97.7, P 53, R 20,

B/P 127/77

CBC:
RBC 3.03 L
H/H 9.4/27.5 L
BMP:
Cl- 108 H
BUN 3 L
Ca2+ 7.9L
Magnesium 1.7 L