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Nursing Care Plan

Cues Nursing Analysis Goal and Interventions Rationale Evaluation


Diagnosis Objectives

Subjective: Acute pain The client is Goal: After 12- The client’s pain
The client related to experiencing pain hours shift, the was lessened.
verbalized post-op due to the client’s pain will be
-“masakit surgical episiotomy done to lessened.
talaga yung incision her after the CS
tahi ko, operation. Objective: DEVELOPMENTAL:
nahihiripan Pain is a typical
ako gumalaw” sensory experience > After 5 minutes, Perform a Pain is a subjective The client was
-“hindi ko that may be the client will comprehensive experience and must be able to verbalize
magawa mapa described as the verbalize the assessment of pain described by the client to characterize
dede anak ko unpleasant characteristic and to include location, in order to plan and locate the
magisa dahil awareness of a location of pain. characteristics, effective treatment. pain.
sa sakit” noxious stimulus or onset, duration,
-“siguro nasa bodily harm. frequency, quality,
‘6’ (10 Individuals intensity or
highest) ang experience pain by severity, and
sakit niya.” various daily hurts precipitating factors
-“hindi talaga and aches, and of pain.
ako occasionally through
makagalaw more serious injuries DEVELOPMENTAL:
dahil sa tahi, or illnesses.
nakakinis nga > After 10 minutes Teach the use of The use of noninvasive The client was
eh” (http://en.wikipedia.or client will be able non-pharmacologic pain relief measures can able to perform
g to perform pain techniques: increase the release of deep breathing
Objective: /wiki/pain) management: endorphins and exercise.
-deep breathing
-presence of -deep breathing technique enhance the therapeutic
grimace technique effects of pain relief
-on guarding medications.
position
during the
interview
-pale FACILITATIVE:
-RR: 24
breath/min > On the given Provide optimal Each client has a right The client was
time, administer pain relief with to expect maximum able to take her
pain reliever to the doctor’s prescribed pain relief. Optimal pain due med.
client. analgesics. relief using analgesics
includes determining
the preferred route,
drug, dosage, and
frequency for each
individual. Medications
ordered on a prn basis
should be offered to the
client at the interval
when the next dose is
available.

SUPPLEMENTAL:

> After every 4 Monitor client’s Assessment of vital The client’s vital
hours, the client’s vital signs signs is an important signs were
vital signs will be including: blood component of the monitored.
monitored. pressure, physical therapy
respiratory rate, examination and should
pulse rate and be included in the
temperature. examination of all
patients. Knowledge of Efficiency
vital signs allows the The time,
therapist to understand materials, and
a patient's physiologic human resources
status and is helpful in were used
determining appropriate economically
goals.

Adequacy
The numbers of
interventions were
sufficient.

Appropriateness
The interventions
were suitable to
the client’s
situation.

Acceptability
The interventions,
setting, and
timetable were
realistic to the
client’s situation.