B. Nursing Care Plan

ASSESSMENT NURSING DIAGNOSIS

ANALYSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective:“Sumasakit pa nga yung tahi ko dito sa parteng ni-ligate at sa cs ko”

Objective:Facial mask of pain

(+) Guarding position while we are interviewing her.

Acute pain related to post-op surgical incision as evidenced by facial mask of pain.

The patient experiences pain because of the incision done to her after her CS and BTL operation.Pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage .

(http://www.pain-management-info.com/definition-of-pain.htm)

GOALAfter 8 hours of nursing intervention, the patient’s pain will be minimized. OBJECTIVESAfter 5 minutes, the client will verbalize the characteristic and location of pain.

After 10 minutes the client will be able to perform pain management like; Deep breathing

technique

On the right time

Perform a comprehensive assessment of pain to include location,characteristics, onset, duration, frequency, quality, intensity orseverity, and precipitating factors of pain.

Teach the use of non-pharmacologic techniques:Deep breathing technique

Pain is a subjective experience and must be described by the patient in order to plan effective treatment.

The use of noninvasive pain relief measures that can increase the release of endorphins and enhance the therapeutic effects of pain

The patients pain minimized.

The patient was able to verbalize, to characterize and locate the pain.

The patient was able to perform deep breathing exercise.

The patient was

given, administer pain reliever to the client.

After every 4hours, the vital signs of the patient will be

Provide optimal pain reliever with doctor’s prescribed analgesics.

Monitor the patients vital signs

relief medications.

Each client has aright to expectmaximum pain relief.Optimal pain reliefusing analgesicsincludes determiningthe preferred route,drug, dosage, andfrequency for eachindividual.Medications orderedon a prn basis shouldbe offered to theclient at the intervalwhen the next doseis available.

Assessment of vitalsigns is an important

able to take her due medications.

The patient’s vital signs were monitored.

monitored. component of thephysical therapyexamination andshould be included inthe examination ofall patients.Knowledge of vitalsigns allows thetherapist tounderstand apatient's physiologicstatus and is helpfulin determiningappropriate goals