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Nursing Care Plan

CUES NURSING DIAGNOS IS Acute Pain related to postoperati ve surgery ANALYSIS GOAL and OBJECTIVES GOAL: After the 8 hours of nursing intervention, the client will verbalize feeling of comfort and relief. INTERVENTION RATIONALE EVALUATION

Subjective Cues: The client verbalized: Masakit pa din ang tahi ko

Objective Cues:

Slow and weak movements facial grimace

Unrelieved pain presents both physiologic and psychologic dangers to health and recovery. Severe pain is viewed as an emergency situation deserving attention and prompt treatment. (Kozier., B. et al.Fundamentals of Nursing. 7th ed. Chap 44 Pain Mgt. p. 1133) Postoperative pain is defined as an acute or chronic pain that is experienced after an operation or surgical

Objectives: After nursing intervention, the client will be able to;

After 2 day-shift of nursing intervention, the client was able to verbalize feeling of comfort and relief evidenced by absence of facial grimace and weakness. The client maintained a normal pulse rate, accurate input and output, and free from any complications that is brought by pain.

Goal met. 1. 1. The client will be able to verbalize and express the pain she is feeling.


temp- 36 PR- 62bpm RR- 20cpm Bp- 110/60

Perform an assessment of pain include location, characteristics, onset, duration, frequency, quality, intensity or severity and

Pain is a subjective experience and must be described by the client in order to plan effective treatment. -Fundamentals of

procedure. While significant strides have been made in medicine in this regard, postoperative pain management can be quite difficult, especially in situations where the body sustained some physical trauma due to the operation itself. After extremely invasive procedure's, it is to d safe to say that nearly all patients experience some degree of postoperative pain - however, the severity will dictate what kind of treatment the

precipitating factors of pain. Use of pain scale from 1 to 10.

Nursing by Kozier p. 1164-1165

2. The client will be able to perform nonpharmacologic/rel axation techniques.

Teach the use of nonpharmacologic/ relaxation techniques before, after, if possible during painful activities; before pain occur or increases and along with other pain relief measures such as:

Relaxation techniques help reduce skeletal muscle tension, which will reduce the intensity of the pain. -Fundamentals of Nursing by Kozier p. 11641165

medical staff will provide while the patient is hospitalized. If postoperative pain persists upon release from the hospital, pain medications and physical therapy treatments may have to continue for some time on an outpatient basis. http://www.googl e.com.ph/#hl=tl& biw=1024&bih=6 17&q=postoperati ve+pain&aq=f&a qi=g6&aql=&oq= &fp=dfa119032fb f1b4e

Massage, repositioning and relaxation techniques.,

3. The client will be able to cooperate with the simple relaxation therapy through performance and practice.

Assist the client in practicing the nonpharmacologi c/ relaxation techniques with the client.

Return demonstrations by the participant provide an opportunity for the nurse to evaluate the effectiveness of teaching sessions. -Fundamentals of Nursing by Kozier p. 11641165

Collaborate with patient in

4. The client will collaborate in administering prescribed analgesics when alternative methods of pain control are inadequate. .

administering prescribed analgesics when alternative methods of pain control are inadequate.

Gaining patients trust and involvement helps ensure compliance.