NURSING CARE PLAN FOR CESARIAN SECTION

ASSESSMENT

Status post CS under

spinal anesthesia;
With no movement
and no sensation of
lower extremities
Autonomic
Responses
(changes in vital
signs and neuro vital
signs)

NURSING
DIAGNOSIS

EXPECTED
OUTCOME

Altered Motor
and Sensory
Function related
to post anesthetic
effect

After 2 hours of
nursing
intervention
patient will be able
to regain motor
and sensory
function of lower
extremities.

NURSING INTERVENTION

Monitor O2 saturation, vs and nvs.

Keep side rails up.

RATIONALE

To have a baseline data of patients

status.
To maintain patient safety.

Maintained flat on bed.

To prevent spinal headache and other

complications.

Reassess for motor and sensory response of

lower extremities.

To assess the location of spinal

anesthetics.

Reorient patient to effects of anesthesia.

To give proper information to clients

and prevent anxiety.

Reassure patient to regain movement and

sensation of lower extremities after 2-3
hours.
Monitor for untoward signs and symptoms.

To prevent patient anxiety.

To continuously assess for patient
status and other effects of anesthesia.

NURSING CARE PLAN FOR CESARIAN SECTION

1

EVALUATION

Patient is able to move

and flex lower
extremities gradually.

ASSESSMENT

Presence of
surgical incision,
Wound dressing

NURSING
DIAGNOSI
S

High risk for

infection
related to
interruption of
skin barrier/
invasive
procedures.

EXPECTED
OUTCOME

After 2 hours of
nursing
intervention
patient able to
identify
intervention to
reduce risk of
infection,
achieve timely
wound healing ,
be free of
purulent
drainage or
erythema; be
afebrile

NURSING INTERVENTION

Observe for signs of infection at surgical site,

assess and document skin conditions noting
inflammation and drainage.
Stress proper hand washing techniques by all
caregivers
Monitor for changes in body temperature
Change dressing as needed and cleanse
incision sites daily and prn with povidoneiodine solution.
Use gloves when caring for open lesions

RATIONALE

Assess causative/ contributing factors

.First line defense against nosocomial

infections
Changes in body temperature may indicate
signs of systemic infection
To reduce risk of local and systemic
infection.

Monitor medication regimen

Assist patient or significant others to learn
about protecting the skin integrity and
preventing spread of infection.
Proper education to patient and relatives will
ensure continuing of proper care and
eliminate risk of infection.

NURSING CARE PLAN FOR CESARIAN SECTION

2

EVALUATION

Patient verbalized
understanding of
individual causative
risk factors and
demonstrate
techniques, lifestyle
changes to promote
safe environment
and able to achieve
timely wound
healing

ASSESSMENT

Under spinal
anesthesia;
With indwelling
catheter connected
to urine bag
draining to light
yellow colored
urine

NURSING
DIAGNOSI
S

Potential for
urinary
Retention
related to post
anesthetic
effect

EXPECTED
OUTCOME

After 2 hours of
nursing
intervention
patient will be
able to maintain
adequate
amount of
intake and
output

NURSING INTERVENTION

RATIONALE

Maintain indwelling catheter patent and

secured in place.

To assure continues urine elimination.

Monitor for changes in vital signs.

Look for signs of bladder distention.

Increase in BP and bladder distention may

indicate urine retention.

Regulate IV fluid at prescribed rate.

To replace fluid loss accurately.

Measure and record intake and output.

To provide precise data on urine elimination.

NURSING CARE PLAN FOR TAHBSO

EVALUATION

Patient has adequate

intake and output.

ASSESSMEN
T

NURSING
DIAGNOSIS

Irritability,
impaired physical
mobility,
disturbed sleep
pattern, facial
mask,
diaphoresis,
restlessness,
facial grimaces

Acute pain
related to
surgical
operation

EXPECTED
OUTCOME

After 2 hours of
nursing
interventions, the
patients pain
scale will
decrease 10/10 to
5/10.

NURSING INTERVENTION

RATIONALE

Establish rapport
Monitor vital signs

To gain trust
To obtain baseline data

Provide comfort measure

To satisfy the confinement of patient

Encourage deep breathing

To inhibit pain

Provide safety measure

To prevent from injury

Develop communication

To alter pain and diminish emotional stress

Review procedures/expectations and tell

client when treatment will hurt

To reduce concern of unknown and

associated muscle tension.

Administer analgesics as indicated to

maximal dosage as needed.

To maintain acceptable level of pain.

NURSING CARE PLAN FOR TAHBSO

EVALUATION

The patients pain

scale decreased
From 10/10 to 4/10

ASSESSMEN
T

NURSING
DIAGNOSIS

Temperature of
Hypothermia
36C below,
related to post
manifests shivering anesthetic effect
and cool skin

EXPECTED
OUTCOME

NURSING INTERVENTION

After 2 hours of
Monitor vital signs
nursing
Wrap in warm blanket
interventions the
patient will display
core temperature Avoid use of heat clamps or hot water bottles
within normal
range.
Reorient patient to the effects of anesthesia

RATIONALE

To obtain baseline data

To promote heat
Surface re-warming can lead to re-warming
shock due to surface vasodilatation

Providing information to client may reduce

anxiety

Reassure patient that shivering may subside

after 2-3 hours
Administer fluids during re-warming

To prevent hypovolemic shock

NURSING CARE PLAN FOR TAHBSO

EVALUATION

The patient displayed

core temperature
within normal range.

ASSESSMEN
T

NURSING
DIAGNOSIS

EXPECTED
OUTCOME

Pallor, with dry and Risk for infection After 2 hours of

nursing
intact dressing on secondary to
surgical
incision
interventions, the
the area.
patient shall
identify and
Reports pain over
demonstrate
the incision site.
intervention to
prevent infection
Irritability,
Impaired physical
mobility

NURSING INTERVENTION

RATIONALE

Monitor Vital signs and note signs and

symptoms of sepsis.

To obtain baseline data

Provide wound healing such as cleaning of

wound

To reduce complication and monitor for

infection

Provide care, change dressing as needed

To reduce risk for infection

Encourage increase intake of Vitamin C

To increase immune resistance

Encourage deep breathing exercise

To increase healing of wound

Fever

NURSING CARE PLAN FOR CATARACT

EVALUATION

The patient identified

and demonstrated
interventions to
prevent risk of
infection.

ASSESSMEN
T

Reports changes in
sensory acuity (e.g.
photosensitivity)
Change in usual
response to stimuli

NURSING
DIAGNOSIS

EXPECTED
OUTCOME

Disturbed Sensory Patient will

Perception related improve visual
to Altered Sensory acuity within the
limits of individual
Perception
situations,
recognize
( photo-sensitivity)
disturbance and
compensate against
changes.

NURSING INTERVENTION

Orient client to environment

RATIONALE

To prevent from sensory deprivation

Avoid isolation of patient, physically or

emotionally
Re-orient to time, place, staff an event as
necessary
Provide undisturbed rest/sleep periods.

Patient verbalize
awareness of
To promote normalization of response to
sensory needs and
stimuli
able to recognize
and compensate for
To provide auditory stimulation and prevent
sensory
startle reflex
impairments.
Prompt recognition of side effects allows for
timely intervention/ change in drug regimen.

Speak to visually impaired or unresponsive

patient during care.
Discuss drug regimen

-NCP - NCP
Nursing Service Department
NURSING CARE PLAN FOR CATARACT

EVALUATION

ASSESSMEN
T

NURSING
DIAGNOSIS

Presence of eye pad Risk for Injury

for protection
related to Sensory
covering the
Dysfunction
affected eye.

EXPECTED
OUTCOME

NURSING INTERVENTION

Patient will be free Provide safety measures such as side rails.

from any injury;
Ambulate with assistance or devices
will express
understanding of
the factors involved Maintain eye protection as needed
in the possibility of
injury.
Avoid lying on the affected eye

RATIONALE

To prevent injury
To enhance balance
To prevent further injury to affected eye.

To prevent increase intraocular pressure and

prevent complications

Limit activities that may increase intraocular

pressure (e.g. bending/ stooping, rubbing
eyes/sudden movement of the head/ straining.
Observe for signs of injury (e.g. old/ new
bruises, history of fractures).

To evaluate degree/ source of risk inherent in

the situation

-NCP - NCP
Nursing Service Department
NURSING CARE PLAN FOR CHOLECYSTECTOMY

EVALUATION

Still with eye pad

covering the affected
area.

ASSESSMEN
T

Reports of pain,
Irritated, facial
grimaces, weak
appearance,
complains every
now and then.

NURSING
DIAGNOSIS

EXPECTED
OUTCOME

NURSING INTERVENTION

RATIONALE

After 2 hours of
Pain: Acute r/t
Pain is a subjective experience and cannot be
disruption of skin, nursing intervention Assess the location/ site, characteristics,
duration, frequency, quality and severity of
felt by others
tissue secondary to the patient will
pain.
Perform
assessment
each
time
pain
occurs
surgical incision report that pain is
and to note changes from previous reports.
(open cholecys- lessened from a
pain scale of 8/10 to
tectomy )
Perform assessment each time pain occurs.
Evaluate patient response to pain
2/10.
Assist patient to explore methods for
Encourage to verbalize feelings of discomfort. alleviation and control of pain
Provide quiet environment and encourage
adequate rest period.

Promotes relaxation and enables patient to

refocus attention; may enhance coping.

Encourage use of relaxation technique and

diversional activities. Encourage deep
breathing exercises
To administer analgesics as ordered

-NCP - NCP
Nursing Service Department
NURSING CARE PLAN FOR CHOLECYSTECTOMY
9

EVALUATION

Patient report
alleviation of pain
able to demonstrate
use of relaxation
exercises to reduce
pain and follows
prescribed
pharmacologic
regimen.

ASSESSMEN
T

NURSING
DIAGNOSIS

With dressing intact Impaired skin and

at right upper
tissue integrity
quadrant.
related to post
Disruption of skin surgical
surface, destruction procedure.
of skin layers.

EXPECTED
OUTCOME

NURSING INTERVENTION

Keep dressing intact, dry and clean.

After 2 hours of
nursing intervention
the patient will
Assess for signs of bleeding, and
integrity
display timely
of dressing on surgical site.
healing of skin
wounds and will
Provide adequate rest and comfortable
not manifest signs
position.
of bleeding on the
surgical site.
Review important measures to
proper skin functioning

RATIONALE

Assist with bodys natural process of

repair Patient

demonstrates
behavior to promote
To minimize the spread of infection and
healing and prevent
reduce complication.
further skin
Reduces from pressure or tension, providing breakdown.
measure of comfort

To assist in wound healing if needed.

maintain

Provide optimum nutrition and increase

protein intake

To provide a positive nitrogen balance,

aid in healing wound and maintaining
general good health

Advice prescribed therapeutic regimen

-NCP - NCP
Nursing Service Department
NURSING CARE PLAN FOR CHOLECYSTECTOMY

10

EVALUATION

ASSESSMEN
T

Temperature of
36.0C
With dressing
intact.

NURSING
DIAGNOSIS

EXPECTED
OUTCOME

Risk for infection

r/t interruption of
skin barrier
secondary to
surgical incision.

After 2 hours of
nursing
intervention the pt.
will be free of any
signs of infection.

NURSING INTERVENTION

RATIONALE

Monitor vital signs and note signs and

symptoms of sepsis.

To obtain baseline data.

Keep sterile dressing dry and intact,

change dressing as needed.

To reduce risk of infection and reduce

complication.

Provide comfort.
Monitor for changes in body temperature.
Inspect incision and dressings; note for
characteristics of drainage from wound or
drains.

Fever signals that a battle might be going on

in the body.

Failure to treat an infection early can lead

to tissue damage that may require surgery.

Notify your physician for a sudden

increase in swelling or drainage or purulent
drainage.
Administer antibiotics as appropriate.

-NCP - NCP
Nursing Service Department
NURSING CARE PLAN FOR EXPLOR LAPAROTOMY

11

EVALUATION

Patient identified and

demonstrated
interventions to
prevent risk of
infection.

ASSESSMEN
T

Hypotension
Tachycardia
Decrease venous
filling
Decrease urine
output
Concentrated urine
Pallor
Decrease skin
turgor

NURSING
DIAGNOSIS

Fluid Volume
Deficit related to
post surgical
procedure.

EXPECTED
OUTCOME

NURSING INTERVENTION

After 2 hours of
Assess vital signs, note strength of peripheral
nursing intervention pulses and physical signs (delayed capillary
patient will
refill, poor skin turgor, etc.)
maintain fluid
Maintain accurate intake and output.
volume at a
Replace electrolytes blood products/ plasma
functional level
expanders as ordered
Administer intravenous fluids as indicated.
Assist patient/ significant others to learn to
measure own I/O.

RATIONALE

Evaluate degree of fluid deficit

Patient maintain fluid

volume at a functional
level as evidenced by
To provide baseline data of patients
stable vital signs,
fluidstatus.
adequate urinary
To replace losses to reverse pathophysiologic output, good skin
turgor, prompt
mechanism
capillary refill
To promote wellness

Refer to attending physician as necessary.

Weakness

-NCP - NCP
Nursing Service Department
NURSING CARE PLAN FOR EXPLOR LAPAROTOMY

12

EVALUATION

ASSESSMEN
T

NURSING
DIAGNOSIS

Increase body
Hyperthermia
temperature 38C related to post
operative fluid
Headache
loss
Flushed skin ,
warm to touch
Presence of chills

EXPECTED
OUTCOME

NURSING INTERVENTION

After 2 hours of
Identify underlying cause (e.g., dehydration,
nursing interventioninfection). Monitor and record all sources of
patient will
fluid loss such as urine, wounds, insensible
maintain core
losses
temperature within
Monitor body temperature, vital signs
normal range.
Monitor respirations hyperventilation may
usually present

RATIONALE

Assess causative factors

Evaluate effects of hyperthermia

Promote surface cooling by means of cool

Reduces body temperature and restore normal
environment, tepid sponge bath, local ice pack body function.
in groin and axillae, light clothing.
Maintain bed rest.

To reduce metabolic demands/ oxygen

consumption.

Provide supplemental oxygen as ordered.

To offset increased oxygen demands and

consumption.

Administer replacement fluids and electrolytes To replace losses/ prevent dehydration.

as ordered.
Administer antipyretics as ordered

-NCP - NCP
Nursing Service Department
NURSING CARE PLAN FOR CRANIECTOMY
13

EVALUATION

Patient maintain
normal body
temperature 37C

ASSESSMEN
T

NURSING
DIAGNOSIS

With Endotracheal Ineffective

tube,
breathing pattern
r/t neuromuscular
Hooked to
dysfunction
Mechanical
Ventilator
Restlessness

EXPECTED
OUTCOME

To achieve
adequate
respiratory
function.
To wean to
mechanical
ventilator.

Delayed capillary
refill

NURSING INTERVENTION

RATIONALE

Maintaining patient on controlled ventilation

as ordered.

To maintain normal ventilator status.

Monitoring Oxygen saturation.

To determine respiratory status.

EVALUATION

Shows signs of
awakening and has
adequate spontaneous
ventilation.

Elevate head of bed 30-450 angle and maintain To aid venous drainage of the brain.
head/neck in midline or neutral position.
Suction trachea and pharynx cautiously.

To remove secretions and prevent aspiration.

With pulse
oximeter

-NCP - NCP
Nursing Service Department
NURSING CARE PLAN FOR CRANIECTOMY
ASSESSMEN
T

NURSING
DIAGNOSIS

EXPECTED
OUTCOME

NURSING INTERVENTION
14

RATIONALE

EVALUATION

Restlessness
Blood pressure
changes
Delayed capillary
refill
Changes in heart
rate rhythm
Altered
consciousness
Behavior changes

Monitor changes in mentation, vital signs,

Assess causative/ contributing factor
Altered Tissue
After 2 hours of
blood pressure, signs of electrolyte imbalance
Perf-NCPon:
nursing
Cerebral related to intervention, patient Assess visual, personality, sensory/ motor
Decrease oxygen will be able to meet changes, such as headache, dizziness, altered Note degree of impairment
mental status
supply to the brain oxygen
requirement.

Elevate head of bed at 10 degrees angle and

maintain head/ neck and midline on neutral
position

These promote circulation and venous

drainage.

Avoid nursing activities that may trigger

increased ICP (positioning with neck in
flexion, head flat).
This help overcome the profound sensory
Provide sensory stimulation (e.g., talking/
deprivation
touching to patient)
Orient to time and place at least once every 8
hours
Monitored closely for evidence of impaired
skin integrity and strategies to prevent skin
breakdown and pressure ulcers

Means of enriching the environment and

providing familiar input.

-NCP - NCP
Nursing Service Department
NURSING CARE PLAN FOR CRANIECTOMY

15

Patient was able to

maintain adequate
oxygenation.

ASSESSMEN
T

NURSING
DIAGNOSIS

EXPECTED
OUTCOME

NURSING INTERVENTION

RATIONALE

Accurately monitor intake/ output

check head dressing for presence of drains

Drains and catheters should be secured to

patient or bed to prevent falls to floor,
negative-gravity suctioning and increased risk
of bleeding or dislodging of drain

Administer medications (e.g., steroid,

diuretics) as ordered

Decreases edema, anticoagulants.

EVALUATION

-NCP - NCP
Nursing Service Department
NURSING CARE PLAN FOR CRANIECTOMY
ASSESSMEN
T

NURSING
DIAGNOSIS

EXPECTED
OUTCOME

NURSING INTERVENTION
16

RATIONALE

EVALUATION

With head
High risk for
dressing secured infection r/t
in place.
decreased primary
defenses.
With JP drain

After 2 hours of
Monitored closely for evidence of impaired
nursing
skin integrity and strategies to prevent skin
intervention patient breakdown and pressure ulcers.
will be able:
Monitor closely for changes in body
To be free of
temperature.
purulent drainage
or erythema.
To be free from
edema.

To reduce any signs of infection or edema.

Patient shows no signs

for edema, and
purulent drainage or
erythema.

Increase in body temperature signifies

systemic infection.

Daily wound care after 24 to 48 hours post

operative.

To prevent risk of infection.

Use measures prescribed to relieve signs of

edema.

Edema is one of post operative inflammatory

response of craniectomy.

To control the emergence infection and

Administer antibiotics and anti inflammatory
control inflammatory response at the surgical
agents as prescribed.
site.

-NCP - NCP
Nursing Service Department
NURSING CARE PLAN FOR CRANIECTOMY
ASSESSMEN
T

NURSING
DIAGNOSIS

EXPECTED
OUTCOME

NURSING INTERVENTION
17

RATIONALE

EVALUATION

With an IVF of
With Indwelling
catheter

Risk for fluid

Patient attains and
To attain and
Assess vital signs, note strength of peripheral To evaluate the degree of fluid imbalance
volume imbalance maintain fluid and pulses and physical signs (delayed capillary
maintains fluid and
r/t post surgical
electrolyte balance.
electrolyte balance. refill, poor skin turgor, etc.)
procedure
Rate and composition depend on fluid deficit,
Administer prescribed intravenous fluids
urine output, and blood loss.
cautiously.
Monitor for polyuria, especially during first
operative week.
Weigh patient daily; keep intake and output
record.

To provide baseline data of patients fluid

status.

Assist patient/ significant others to learn to

measure own I/O.

To promote wellness

Refer to attending physician as necessary.

-NCP - NCP
Nursing Service Department

NURSING CARE PLAN FOR ORIF

18

ASSESSMEN
T

NURSING
DIAGNOSIS

EXPECTED
OUTCOME

Pain on operative Acute pain related Patient describes

site
to post operative discomfort.
procedure
Facial grimace
Expresses
confidence in
Guarded behavior
efforts to control
Autonomic
pain.
responses
(changes in vital
Expresses little
signs)
discomfort with
position changes.

NURSING INTERVENTION

Investigate verbal reports of pain, noting

specific location and intensity (0-10 scale)

RATIONALE

Pain is subjective and is evaluated through

Pain is relieved or
description of characteristics and location
controlled.
which are important for determining cause of
discomfort.

Note factors that aggravate and relieve pain.

Maintain bedrest during acute attack.
Promote position of comfort.

This reduce pressure and tension thus

providing measure of pain relief

Provide quite, restful environment.

Promote relaxation and enables patient to

refocus attention

Administer analgesics in timely manner.

This medicine is used to decrease pain and

lower a high body temperature (fever).

-NCP - NCP
Nursing Service Department
NURSING CARE PLAN FOR ORIF

19

EVALUATION

ASSESSMEN
T

Presence of
immobilizing
device
Limited range of
motion
With dressing
Decrease muscle
strength
Inability to
purposefully move
within the physical
environment

NURSING
DIAGNOSIS

EXPECTED
OUTCOME

NURSING INTERVENTION

RATIONALE

Impaired physical After 2 hours of

Note movement when patient is unaware of
To assess functional ability
mobility r/t post nursing intervention observation.
surgical procedure patient will be able
to maintain level of Assist on proper positioning to maintain proper To deformities and contractures
body alignment.
function of
compensatory body Encourage in active participation in activities To promote maintenance of muscle strength
parts.
and joint mobility
of daily living.
4

Range of motion exercises are initiated as soon Gentle exercises as part of your recovery
program will help avoid blood clots and
as the condition permits.
restore your hip to a full range of motion and
strength
Assist patient to learn safety measures.

To promote wellness

-NCP - NCP
Nursing Service Department
NURSING CARE PLAN FOR CYSTO TURP

20

EVALUATION

Patient maintains or
increase strength and
function of affected
body part.

ASSESSMEN
T

NURSING
DIAGNOSIS

EXPECTED
OUTCOME

NURSING INTERVENTION

Patient verbalized Acute Pain related After 2 hours of

Perform pain assessment each time pain
pain, grimaced face, to Surgical
nursing
occurs
guarded behavior Incision (catheter intervention, patient
Observe nonverbal cues (e.g. facial
placement/ bladder will be able to
expression, cool fingertips/toes
spasm)
alleviate pain.

RATIONALE

To rule out worsening of underlying

condition
Observations may/may not be congruent with
verbal reports
indicating need for further evaluation

Encourage verbalization of feelings about pain To establish baseline data; usually altered in
acute pain
Provide quiet environment, calm activities

To assist patient to explore methods for

alleviation/control pain

Encourage adequate rest periods

Administer analgesics as indicated

To prevent fatigue
To maintain acceptable level of pain and to
control pain

-NCP - NCP
Nursing Service Department
NURSING CARE PLAN FOR CYSTO TURP

21

EVALUATION

Patient verbalized that

pain has lessen.

ASSESSMEN
T

NURSING
DIAGNOSIS

With ongoing
Risk for Fluid
cystoclysis draining Imbalance r/t
to tea colored
presence of
discharge with
ongoing
streaks of blood.
cystoclysis

EXPECTED
OUTCOME

NURSING INTERVENTION

RATIONALE

EVALUATION

After 2 hours of
Keep on going cystoclysis patent and secured To ensure efficiency of the cystoclysis
Still with cystoclysis
in
place.
nursing
With adequate amount
intervention, patient
Measure and record I&O accurately: monitor To assess imbalances in fluid levels
of intake and output
will maintain
urine output
adequate amount of
intake and output. Monitor for signs of bladder distention and
To note signs of fluid retention in cystoclysis.
increase in blood pressure.
Note color, characteristics, consistency and
appearance of output.

To evaluate signs of bleeding at operative site.

Administer IV fluids as prescribed

To prevent imbalances in fluid levels

Administer diuretics as prescribed

-NCP - NCP
Nursing Service Department
NURSING CARE PLAN FOR OR PLATING

22

ASSESSMEN
T

Presence of
immobilizing
device
Limited range of
motion
With dressing

NURSING
DIAGNOSIS

EXPECTED
OUTCOME

RATIONALE

Impaired physical After 2 hours of

Note movement when patient is unaware of
To assess functional ability
mobility r/t post nursing intervention observation.
surgical procedure patient will be able
to maintain level of Assist on proper positioning to maintain proper To deformities and contractures
body alignment.
function of
compensatory body Encourage in active participation in activities To promote maintenance of muscle strength
parts.
and joint mobility
of daily living.

EVALUATION

Patient maintains or
increase strength and
function of affected
body part.

Decrease muscle
strength

Range of motion exercises are initiated as soon Gentle exercises as part of your recovery
program will help avoid blood clots and
as the condition permits.
restore your hip to a full range of motion and
strength

Inability to
purposefully move
within the physical
environment

ASSESSMEN
T

NURSING INTERVENTION

Assist patient to learn safety measures.

NURSING
DIAGNOSIS

EXPECTED
OUTCOME

NURSING INTERVENTION

23

To promote wellness

RATIONALE

EVALUATION

Irritability,
impaired physical
mobility,
disturbed sleep
pattern, facial
mask,
diaphoresis,
restlessness,
facial grimaces

Acute pain
related to
surgical
operation

After 2 hours of
nursing
interventions, the
patients pain
scale will
decrease 10/10 to
5/10.

Establish rapport
Monitor vital signs

To gain trust
To obtain baseline data

Provide comfort measure

To satisfy the confinement of patient

Encourage deep breathing

To inhibit pain

Provide safety measure

To prevent from injury

Develop communication

To alter pain and diminish emotional stress

Review procedures/expectations and tell

client when treatment will hurt

To reduce concern of unknown and

associated muscle tension.

Administer analgesics as indicated to

maximal dosage as needed.

To maintain acceptable level of pain.

24

The patients pain

scale decreased
From 10/10 to 4/10