Saint Joseph College Institute of Health Science Cavite City

NURSING CARE PLAN

Name: Jacob Smith___________________ Address:_____________________________ Chief Complaint:____________________ Assessment Goals and desired outcome Pain r/t break in the continuity of the skin as manifested by: Restless Irritable Facial grimace Pain scale of 6, 10 being the highest Rr 31 cycle/min. Pr 108 bpm Bp 140/100 mmhg Age: 28 y/o Sex: male Clinical manifestation: Post operative Plannig Goals and desired Scientific rationale outcome Transduction After 1-2, with phase the help of The noxious nursing and stimuli(tissue medial injury) intervention patients pain will be lessen as Trigger the manifested by: release of Not restless prostaglandins, Not irritable bradykinin, Less facial serotonin, grimace histamine, Pain scale of 6, substance p 10 being the highest Transmission Rr 20 Pain impulses cycle/min. travels from the Pr 100 bpm peripheral nerve Bp 120/80 fibers to the mmhg spinal cord(dorsal The patient will horn) verbalized I feel less pain Religion:___________ Rm No.:_____________ Bed No.:______ Date of admission:___________________ Evaluation After 1-2, with the help of nursing and medial intervention the goal was partially met as evidence by: Not restless Not irritable Facial grimace Pain scale of 4, 10 being the highest Rr 20 cycle/min. Pr 100 bpm Bp 120/80 mmhg I feel less pain on my incision site as verbalized by

Cues/Evidences SUBJECTIVE: I feel the pain over my incision As verbalized by the patient OBJECTIVE: Restless Irritable Facial grimace Pain scale of 6, 10 being the highest Rr 31 cycle/min. Pr 108 bpm Bp 140/100 mmhg

Implementation Nursing Rationale for order/Action action Independent: To have Monitor vital baseline for signs the succeeding mgt. To be comfortable Place the patient in comfortable position To provide relaxation Instruct to do deep breathing exercise To decrease Eliminate pain stimuli additional stressors or sources of discomfort To facilitate Provide comfort, sleep adequate rest and relaxation period Dependent:

C-fibers (slow transmission of burning chronic pain) From the spinal cord it will travel from spinothalamus tracts going to the brainstem and thalamus Transmission of signal between the thalamus Somatic sensory cortex Ref. fundamental of nursing by kozier, p.1143

on my incision site

Administer analgesic as ordered by the physician

the patient