XI.

NURSING CARE
PLAN
Assessment Nursing Nursing Goals Nursing Rationale Evaluation
Diagnosis Analysis Intervention

Subjective: Acute pain Unpleasant Objectives: Independent:

related to sensory and After 8 hours Outcome met.
“Masakit pa yung post- emotional of nursing 1. (C) Assess pain Helps to determine The patient was
tahi ko, medyo operative experience interventions, characteristics: appropriate relieved
nahihirapan pa ako surgical arising from the patient will • Quality (e.g., interventions to be completely
sharp, without any post-
gumalaw” as incision actual or be able to: use and to rule out
burning, operative
verbalized by the potential worsening of complications
patient tissue damage a. Verbalize shooting) underlying after applying
or described gradual • Severity (scale conditions or comfort
Objective: in terms of reduction/ of 1 to 10, development of measures. In the
with 10 being
such damage adequate complications long run, she
the most
• Restlessness (International relief of pain severe)
displayed a
• Exhibits facial Association for sense of well-
• Location
study of pain); b. Exhibit being and relief
grimace upon (anatomical
sudden or comfort on out of bed (no
movement description)
longer subjected
• Paleness slow onset of bed • Onset to complete bed
• Guarding any intensity (gradual or rest). She
behavior from mild to c. Start sudden) became
severe with an following • Duration (how responsible for
• Sleep
anticipated or measures that long; alleviating the
disturbance intermittent or
predictable provide pain she felt.
• Vital signs taken continuous)
end and a comfort e.g. Consequently,
as follow: • Precipitating she learned to
duration of adhering to
or relieving report during the
less than 6 prescribed
T: 36.5°C factors onset of pain and
months pharmacologic May try to tolerate
RR: 18 discomfort but
al regimen rather than
breaths/min 2. (a, E) Encourage eventually
Source: and request analgesics ceased to do so
PR: 76 patient to report
NANDA 11th nonpharmacol because the
beats/min pain.
edition page ogic methods To prevent further condition was
BP: 110/90
498 to provide complication and successfully
mmHg 3. (C) Monitor vital
relief to determine signs managed.
signs
of infection

To promote non-
pharmacological
4. (b, B)Provide
pain management
 comfort
Goals: measures (e.g.
After nursing touch,
interventions, repositioning,
the patient use of cold/hot To evaluate the
will be able to: packs, nurse’s client’s response
presence) to pain. Pain is a
A. Achieve subjective
complete 5. (D) Accept experience and
relief of client’s cannot be felt by
pain description of others
B. Exhibit pain.
wellness Acknowledge
and the pain
comfort out experience and Body language/
of bed convey nonverbal cues
C. Prevent acceptance of may be both
complicatio client’s physiological and
ns and response to pain psychological and
infection may be used in
D. Assume 6. (D) Note conjunction with
responsibili nonverbal cues verbal cues to
ty for such as determine the
alleviation reluctance to extent or severity
of move and of the problem
discomfort abdominal
E. Report guarding. The use of
successful noninvasive pain
manageme relief measures
nt of pain can increase the
release of
endorphins and
7. (c) Teach the enhance the
use of non- therapeutic effects
pharmacologic of pain relief
techniques, medications.
such as focused
breathing, Patients may
imaging, experience an
CDs/tapes (e.g. exaggeration in
 “white” noise, pain or a
music, decreased ability
instructional) to tolerate painful
stimuli if
8. (D) Eliminate environmental,
additional intrapersonal, or
stressors or psychological
sources of factors are further
discomfort stressing them
whenever
possible To prevent fatigue
and to facilitate
comfort, sleep,
and relaxation

9. (b, B) Encourage Pain medications

adequate rest are absorbed and
periods metabolized
differently by
Dependent: patients, so their
effectiveness must
10.(c, A) Give be evaluated from
analgesics as patient to patient.
ordered, Analgesics may
evaluating cause side effects
effectiveness that range from
and observing mild to life-
for any signs threatening
and symptoms
of untoward
effects
To promote active,
not passive, role
and enhances
sense of control
Interdependent:

11.(b, B) Provide
 for
individualized
physical
therapy/
exercise
program that
can be
continued by
the client after
discharge

Legends: (b) – pertains to the corresponding objective (B) – pertains to the corresponding goal (b, B) – pertains to the corresponding objective
and goal