NURSING CARE PLAN # 1

ASSESSMENT DIAGNOSIS(NANDA-BASED)

PLANNING IMPLEMENTATION RATIONALE(cite sources)

EVALUATION

(ACTUAL)Subjective cues:

- “Dili na kaayo sakit”, verbalized by the patient.

- Pain Scale of 4 out of 10

Objective cues:

- Incision in the lower abdomen

- Guarding Behavior

- Facial grimace

- Positioning to avoid pain

Acute Painr/t to Tissue

Trauma Secondary to Status Post

TAHBSO (Total Abdominal

Hysterectomy Bilateral Salphingo

Oophorectomy)

Short term:

After 3 hours of nursing interventions:

1. the client will state 3ways of relieving pain such as imagery, application of hot and cold compress and therapeutic touch

2. the client’s pain scale will decrease from 4 to 2.

Long term:

At the end of 24 hours, patient will rate pain as 0 out of 10

Independent

1. Instruct client to report any improvement/exacerbation in pain experience.

2. Encourage and assist client to do deep breathing exercises.

3. Encourage adequate periods of rest and sleep, including uninterrupted periods of sufficient duration, meeting comfort needs, limiting/ avoiding use of caffeine/ alcohol and medications affecting REM sleep. Encourage quiet, restful atmosphere.

4. Discuss with relatives the importance of early detection and reporting of changes in condition or any unusual physical discomforts/ changes.

5. Teach the client and significant others about the nonpharmacologic ways to lessen pain.

6. Increase intake of Vitamin C

7. Monitor Vital signs

1. Unrelieved pain can create other problems such as anger, anxiety, immobility, respiratory problems, and delay in healing. (Medical-Surgical Nursing, 7thed. by Black, Joyce M. and Jane Hokanson Hawks; p. 443

2. Deep breathing for relaxation is easy to learn and contributes to pain relief and/or reduction by reducing muscle tension and anxiety. (Medical-Surgical Nursing, 7th ed. by Black, Joyce M. and Jane Hokanson Hawks; p. 479

3. To prevent fatigue. (Nurse’s Pocket Guide, 9th ed. by Doenges, Marilynn, et.al., p. 369)

4. Promotes early detection of developing complications. (Fundamentals of Nursing 7th

ed. by Kozier, Barbara, p. 536)

5. It may be possible to teach clients a combination of these techniques to

Short term:Pain is reduced controlled to a tolerable extent as verbalized. Relieving methods are understood and demonstrated,

Long term:

Collaborative/Dependent:

8. Administer medications (particularly analgesics) as prescribed.

maximize their opportunities for self-control over manifestations of pain. (Medical-Surgical Nursing, 7th ed. by Black, Joyce M. and Jane Hokanson Hawks; p. 476)

6. To promote healing of wound. (Nutrition and Diet Therapy by Peckenpaugh page 328)

7. An information baseline comparison from previous data. (Manual of Nursing Procedures Vol. I by Locquiao, Cruz, Arguelles and Lontoc page122)

8. Necessary for treatment of the underlying cause. (Nurse’s Pocket Guide, 9th ed. by Doenges, Marilynn, et.al., p. 542) To maintain acceptable level of pain. (Nurse’s Pocket Guide, 9th ed. by Doenges, Marilynn, et.al., p. 368)