Nursing Care Plan

Cues

Nursing
Diagnosis

Analysis

Goal and
Objectives

Subjective:
The client
verbalized
-masakit
talaga yung
tahi ko,
nahihiripan
ako
gumalaw
-hindi ko
magawa
mapa dede
anak ko
magisa dahil
sa sakit
-siguro
nasa 6 (10
highest) ang
sakit niya.
-hindi
talaga ako
makagalaw
dahil sa tahi,
nakakinis
nga eh

Acute pain
related to
post-op
surgical
incision

The client is
experiencing pain
due to the
episiotomy done
to her after the CS
operation.
Pain is a typical
sensory
experience that
may be described
as the unpleasant
awareness of a
noxious stimulus
or bodily harm.
Individuals
experience pain
by various daily
hurts and aches,
and occasionally
through more
serious injuries or
illnesses.

Goal: After 12hours shift, the

clients pain will
be lessened.

(http://en.wikipedia.
org
/wiki/pain)

> After 10
minutes client
will be able to
perform pain
management:
-deep breathing
technique

Objective:
-presence of
grimace
-on guarding
position
during the
interview
-pale

Objective:
> After 5
minutes, the
client will
verbalize the
characteristic
and location of
pain.

Interventions

Rationale

Evaluation
The clients pain
was lessened.

DEVELOPMENTAL
:
Perform a
comprehensive
assessment of
pain to include
location,
characteristics,
onset, duration,
frequency,
quality, intensity
or severity, and
precipitating
factors of pain.
DEVELOPMENTAL
:
Teach the use of
nonpharmacologic
techniques:
-deep breathing
technique

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

The client was

able to verbalize
to characterize
and locate the
pain.

The use of
noninvasive pain
relief measures can
increase the release
of endorphins and
enhance the
therapeutic effects of
pain relief
medications.

The client was

able to perform
deep breathing
exercise.

The client was

-RR: 24
breath/min

> On the given

time, administer
pain reliever to
the client.

> After every 4

hours, the
clients vital
signs will be
monitored.

FACILITATIVE:
Provide optimal
pain relief with
doctors
prescribed
analgesics.

Each client has a

right to expect
maximum pain relief.
Optimal pain 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.

The clients vital

signs were
monitored.

SUPPLEMENTAL:
Monitor clients
vital signs
including: blood
pressure,
respiratory rate,
pulse rate and
temperature.

able to take her

due med.

Assessment of vital
signs is an important
component of the
physical therapy
examination and
should be included in
the examination of
all patients.
Knowledge of vital
signs allows the
therapist to
understand a
patient's physiologic
status and is helpful
in determining
appropriate goals.

Efficiency
The time,
materials, and
human
resources were
used
economically

Adequacy
The numbers of
interventions
were sufficient.

Appropriateness
The
interventions
were suitable to
the clients
situation.
Acceptability
The
interventions,
setting, and
timetable were
realistic to the
clients
situation.