Nursing Care Plan

CUES/EVIDENCES NURSING PLANNING NURSING INTERVENTION EVALUATION

DIAGNOSIS
INTERVENTION RATIONALE
Date & Time: Acute Pain Within 8 hours of INDEPENDENT: - To gain After 8 hours of
September 7, 2010 related to post- nursing interventions - Establish trust and nursing
(8:00 AM) operative patient will manifest rapport promote interventions,
incision at left a decrease in pain cooperatio patient manifested a
S: “Nag undergo man breast scale from 8/10 to n. decrease in pain to
ko ug mastectomy sa secondary to 5/10: 5/10.
left breast last August mastectomy as - Perform pain - To assess
14. Hantud karon manifested b y a. Verbalize assessment. etiology a. GOAL
sakit lang gihapon pain scale of understanding and MET.“ Ang
ang gi- operahan. ” 8/10. of the cause contributin sakit na
of pain. g factors. akong gibati
O: Rationale: - Accept patient’s - Pain is a karon kay
- Pain scale of b. Identify ways description of subjective tungod sa
8/10 at the site Post-surgical to alleviate pain. experience pagpa opera
of operation; 0 pain is a pain. and cannot nako. ”
being the complex be felt by
lowest and 10 response to c. Participate in others. b. GOAL
being the tissue trauma care and - Monitor vital - Usually MET.
highest during surgery pharmacologi signs. altered in “Mawala –
- Sharp, that stimulates cal regimen. acute pain. wala jud ang
intermittent hypersensitivit sakit pag
pain radiating y of the central d. Demonstrate - Instruct patient - Timely mag relax
from the post- nervous use of to report pain as interventio lang ko, og
surgical site to system. The relaxation soon as n is more dili
left arm site of the techniques to possible. likely to be magpalabi
- Slight redness surgery has a reduce pain. successful ug lihok.”
and warmth profound effect in
on the incision upon the alleviating
 site noted degree of pain. c. GOAL
- Facial postoperative MET.
grimace noted pain a patient - Provide quiet - To provide “Nagatuman
- Guarding may suffer. environment nonpharma jud ko sa
behavior Right after and comfort cological mga gina
noted mastectomy, measures pain rekomenda
- Slight some women manageme na tambal sa
irritability have nt. akoa kay
noted numbness, and para man
- Vital Signs: pain in the - Encourage deep - To lessen pud na sa
Temperature affected breast breathing and sense of akong
of 36.1 (surgical site) some anxiety kaayuhan.”
degrees hand, arm, and diversional and
Celsius shoulder. activities. associated
Pulse Rate of muscle d. GOAL
tension. MET. “ Ma-
Respiratory relax ko pag
rate of - Encourage - To magbasa ko
ambulation but promote og Bibliya
- BP of 120/80 note when pain circulation pati pag mag
mmHg occurs and ampo ko kay
determine mawala sa
tolerance akong isip
ang kasakit.”
- Encourage - To prevent
adequate rest fatigue
periods

DEPENDENT

- Administer - To
analgesics as maintain
 ordered. acceptable
level of
pain.

- Identify specific - To
signs and promptly
symptoms of identify
infection on the underlying
surgical site condition

COLLABORATIVE

- Provide for - Promotes

individualized active, not
physical passive
therapy/ role.
exercise
program that
can be
continued by
the patient
when
discharged