Reyes, Wilda Rio S.

BSN142
Nursing Care Plan
ASSESSMENT DIAGNOSIS INFERENCE GOALS AND INTERVENTION RATIONALE EVALUATION
OBJECTIVES

SUBJECTIVE: Acute pain Pain is an Goal: After 8 hours of

“Ang sakit-sakit related to unpleasant After 8 hours of nursing
ng tyan ko” distention of sensory and nursing intervention the
the intestinal emotional intervention the client was able
Pain scale: 8/10 tissues by experience client will be to report that
inflammation associated with able to report pain is
OBJECTIVE: as evidence by actual or that pain is controlled with
verbal reports potential tissue controlled with the use of
• Expressive and guarding damage the use of relaxation skills
behaviour of behaviour (Merskey & relaxation skills to promote
pain: criying, Bogduk, 1994). to promote comfort as
irritability It is the most comfort evidence by
common decreased level
• Pale reason for Objectives: of pain scale
appearance seeking health 1.Evaluate 1. Encourage Only the client can from 8 to 2.
care. It occurs clients response verbalization of judge the level and
• Facial with many to pain feelings about the distress of pain; pain
grimace: upon disorders, pain. management should
palpation of diagnostic be a team approach
the RLQ of the tests, and that includes the
abdomen treatments. It client.
disables and
• Gaurding distresses 2. Reassess each To rule out worsening
behaviour: more people time pain occurs: of underlying
body malaise than any single location, condition/developmen
disease. characteristics, t of complication
• Vital signs: (Brunner & onset, frequency,
Temp: 36.5 Suddarth. intensity.
Pulse: 88 Medical-
RR: 25 Surgical 2.Control pain 3. Encourage The human body is
BP: 110/80 Nursing. 10th relatives to believed to have
edition. 2004. perform touch energy fields that
p. 217) therapy. express aberrant
 patterns when body
systems are insulted

4. Provide If the client is ill,

psychological ascertain the
support motivation for
motivation. returning to an optimal
level of wellness

5. Reposition the Reduces

patient slowly and muscle tension
deliberately. and to minimize pain
of movement.

3. Assist client 6. Provide comfort Reduces abdominal

to explore measure: distention, thereby
methods for Maintain reduces tension.
alleviation semifowler’s
position.

7. Encourage and Relaxation and

assist client to do controlled breathing
deep breathing are used to decrease
exercise anxiety and increase
coping mechanisms.

8. Encourage use To distract attention

of relaxation and reduce tension.
technique such as
imaging, music
(cd’s/tapes).

9. Provide comfort Reduces nausea and

measure like vomiting, which can
back rubs increase intra-
abdominal pressure or
pain.

10. Provide To maintain

frequent acceptable level of
oral care. Remove pain and to promote
noxious comfort
environmental
stimuli.

COLLABORATIVE:

11. Administer Certain drugs are

analgesic, as useful for removing or
indicated altering the intensity of
painful stimuli.