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Nursing Care Plan

The document outlines a plan to address a patient's pain following a surgical procedure, including assessing the patient's pain level and vital signs, teaching relaxation techniques, and administering pain medication if needed while continuing to monitor the patient's status. The evaluation will check if the patient reports feeling comfort and a tolerable pain level of 3 out of 10 as well as stable vital signs.

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Briana Louise Hernandez
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69 views3 pages

Nursing Care Plan

The document outlines a plan to address a patient's pain following a surgical procedure, including assessing the patient's pain level and vital signs, teaching relaxation techniques, and administering pain medication if needed while continuing to monitor the patient's status. The evaluation will check if the patient reports feeling comfort and a tolerable pain level of 3 out of 10 as well as stable vital signs.

Uploaded by

Briana Louise Hernandez
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Assessment PLANNING Implementation Evaluation

Objective Outcome Intervention Rationale

Subjective:  Pt report that pain is 1. Subjective pain 1. better understanding  Monitoring of V/S  Client report of
 “Sobrang sakit po relieved. assessment -asking their pain will better every 2-4 hours. comfort feeling.
mas lalo na sa likod”  Follow prescribed where it hurts, how help you in where  Relaxation  Client report that
as verbalized by the pharmacological long, what makes it you should begin in techniques teaching. pain is tolerable.
patient. regimen. better? Or worse? treating their level of  Administering of  Pain scale is now
 Pain scale is rated 10  Verbalized What have they tried pain prescribed rated 3 out of 10.
out of 10 nonpharmacological to relieve pain?” Use 2. elevated BP, HR, and medication if
Objective: method that provide pain scale to assess RR if patient having a needed.
V/S: T-37.1 relief. pain level lot of pain.
P- 70  Demonstrate use of 2. Assess VS 3. Relaxation
R- 18 relaxation skills and 3. Teaching of techniques can help
BP- 110/80 diversional activities, relaxation relieve the pain.
 Pt is crying, facial as indicated. techniques. 4. To control the pain.
grimacing, have a 4. If indicated,
quivering voice, and administer pain
a poor eye contact. medication.
Diagnosis:
 Acute pain r/t
operative procedure

ACTUAL NCP
Potential NCP

Assessment PLANNING Implementation Evaluation

Objective Outcome Intervention Rationale


Subjective:  Verbalize 1. Maintain strict 1. Aseptic technique  Monitoring of V/S  Pt is able to
 “Sobrang sakit po understanding of asepsis for dressing decreases the every 2-4 hours. verbalized infection
mas lalo na sa likod” individual causative changes, wound chances of  Proper cleaning of prevention
as verbalized by the or risk factor. care, intravenous transmitting or the incision/surgery techniques.
patient.  Identify interventions therapy, and spreading pathogens site.  Pt V/S is normal.
 Pain scale is rated 10 to prevent or reduce catheter handling. to or between  Teaching of proper
out of 10 risk of infection. 2. Patient teaching patients. relaxation technique
Objective:  Achieve timely about infection 2. This reduces or to the pt.
V/S: T-37.1 wound healing. prevention eliminates germs.  Encourage the pt to
P- 70 procedures. 3. Adequate sleep is an sleep.
R- 18 3. ensure that any essential modulator  Provide the patient a
BP- 110/80 articles used are of immune clean and well-
 Pt is crying, facial properly disinfected responses. A lack of ventilated
grimacing, have a or sterilized before sleep can weaken environment.
quivering voice, and use. immunity and  Administer
a poor eye contact. 4. Encourage sleep and increased prescribed
Diagnosis: rest. susceptibility to medication.
Risk for infection r/t invasive 5. Administer the infection.
procedure prescribed
medication.
6. Monitor V/S every 2-
4 hours.

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