West Visayas State University

COLLEGE OF NURSING
La Paz, Iloilo
Nursing Care Plan
Name: Attending Physician:
Age: Ward/Bed Number: Impression/Diagnosis:

Clustered Cues Nursing Diagnosis Rationale Outcome Criteria Nursing Interventions Rationale Evaluation

Students Name: SIAN GRACE E. ASADA BSN 4C; RLE Group 2

Clinical Instructor: IAN VAN V. SUMAGAYSAY, RN
11-13-17
4pm Acute Pain related to Unpleasant sensory After the end of shift
incision of the and emotional patient must be able
Nagasakit akon operation performed experience arising from to:
nga tinahian, actual or potential
gangutngot. as tissue damage or 1.
verbalized.
described in terms of
such damage; sudden
Facial grimace
noted or slow onset of any 2.
intensity from mild to
RR:24 bpm severe with anticipated
or predictable end and
PR: 103 bpm
a duration of <6
Pain scale of 5/10 months.
When a patient
undergoes surgery,
tissues and nerve
endings are
traumatized, resulting
in incision pain. This
trauma overloads the
pain receptors that
send messages to the
spinal cord, which
becomes
overstimulated. The
Students Name: SIAN GRACE E. ASADA BSN 4C; RLE Group 2
Clinical Instructor: IAN VAN V. SUMAGAYSAY, RN
1.Assess pain characteristics:
Quality (burning, sharp,
shooting) Severity (scale of 0
or no pain to 10 or most
Report pain is severe) Location (anatomical
relieved or
description) Onset (gradual
controlled. or sudden) Duration (how
Appear relaxed, long; intermittent or
continuous) Precipitating or
able to rest/sleep
and participate relieving factors
in activities
appropriately.
2.Assessed vital signs
3.Placed in a comfortable
position
4. Encourage use of
relaxation techniques: deep-
breathing exercises.
5. Provide rest periods to
03-11-17
1. Assessment of pain After the end of
experience is the first step in shift patient was
planning pain management able to:
strategies. The most reliable
source of information about
the pain is the patient. (Verbalized sense
of relieve)
(Appears relaxed
and calm and
acknowledged
understanding to
2. Changes in these vital health teachings
signs often indicate acute given.)
pain and discomfort.
(Pain scale of
3. May relieve pain and
4/10)
enhance circulation.
4. Relieves muscle and
emotional tension;
enhances sense of control
and may improve coping
abilities.
5. Ones experiences of pain
 resultant central promote relief, sleep, and may become exaggerated as
sensitization is a type relaxation. a result of exhaustion. Pain
of post traumatic stress may result in fatigue, which
to the spinal cord, may result in exaggerated
which interprets any pain. A peaceful and quiet
stimulationpainful or environment may facilitate
otherwiseas rest.
unpleasant. That is why
6. Administer opioid 6. These drugs lessen pain
a patient may feel pain
analgesic as prescribed by by binding with opiate
in movement or
the physician. receptors throughout the
physical touch in
locations far from the body. They work on the
central nervous system so
surgical site.
the side effects associated
with this group of drugs
Sources: http://www.s
urgeryencyclopedia.co tend to be more significant
that those with the NSAIDs.
m/Pa-St/Post-Surgical-
Pain.html#ixzz4bbImlD
P7

Nurses Pocket Guide

12th edition

Students Name: SIAN GRACE E. ASADA BSN 4C; RLE Group 2

Clinical Instructor: IAN VAN V. SUMAGAYSAY, RN