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 MET.
being the tissue trauma care and - Monitor vital - Usually “Mawala –
highest during surgery pharmacologi signs. altered in wala jud ang
- Sharp, that stimulates cal regimen. acute pain. sakit pag
intermittent hypersensitivit mag relax
pain radiating y of the central d. Demonstrate - Instruct patient - Timely lang ko, og
from the post- nervous use of to report pain as interventio dili
surgical site to system. The relaxation soon as n is more magpalabi
left arm site of the techniques to possible. likely to be ug lihok.”
- Slight redness surgery has a reduce pain. successful
and warmth profound effect in c. GOAL MET.
on the incision upon the alleviating “Nagatuman
 site noted degree of pain. jud ko sa
- Facial postoperative mga gina
grimace noted pain a patient - Provide quiet - To provide rekomenda
- Guarding may suffer. environment nonpharma na tambal sa
behavior Right after and comfort cological akoa kay
noted mastectomy, measures pain para man
- Slight some women manageme pud na sa
irritability have nt. akong
noted numbness, and kaayuhan.”
- Vital Signs: pain in the - Encourage deep - To lessen
Temperature affected breast breathing and sense of d. GOAL MET.
of 36.1 (surgical site) some anxiety “ Ma-relax
degrees hand, arm, and diversional and ko pag
Celsius shoulder. activities. associated magbasa ko
Pulse Rate of muscle og Bibliya
tension. pati pag mag
Respiratory ampo ko kay
rate of - Encourage - To mawala sa
ambulation but promote akong isip
- BP of 120/80 note when pain circulation ang kasakit.”
mmHg occurs and
determine
tolerance

- 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