Cebu Normal University

College of Nursing
Cebu City

Mission-Vision: Care Using Knowledge and Compassion

PREOPERATIVE NURSING CARE PLAN

NCP Scoring System 10 pts Defining Characteristics 3 pts Intervention 3 pts

Nursing Dx 2 pts Outcome 1 pt Bibliography 1 pt

Client’s Name: Nellie Limbaga_________________________ Patient Care Classification: (Please Check)

Age: 56 Sex: F Civil Status: Married Religion: Roman Catholic _______ Wholly Compensatory: Pts. Therapeutic self-care is
Allergies: Food: no known food allergies Drug: no accomplished by nurse
known food allergies ________ Partially Compensatory: Pts. Performs some self-care
Diet: DAT __ measures
Date of Admission: May 2, 2011 ________ Supportive Educative Pts. Accomplishes self-care
Diagnosis: Debridement and Possible Orif @ Right Arm_____ measures
Clinical Division and Bed No: FMC-Bed 5________________
Name of Physician: Dr. Duarte ________________________
Name of Student: Al Quin Gayapa __
 DEFINING CHARACTERISTICS
Nursing Diagnosis: Acute Moderate Pain r/t
stimulation of free nerve endings
S: “Sakit akoang kamot” as verbalized
O: received lying on bed, awake and coherent;
with on going venoclysis PLR 1L @ 30 gtts/min
with remaining 800 cc
>with cast @ right arm
>facial grimace noted
>limited range of motion noted
> verbalization of pain when moving
>pain score of 7
OUTCOME CRITERIA INTERVENTION AND Behavioral
Outcome
RATIONALE
Short Term Independent
After 4 hours of nursing intervention, client will I: determine presence of possible
be able to verbalize nonpharmacologic pathophysiologiccal causes of
methods that provide relief pain
R: to asses etiology/precipitating
factor
S: Doenges, et. Al. Nurse’s Pocket
Guide 11 ed. F. A. Davis
Company. Pg. 499
I: note client’s attitude towards
pain
R: to asses etiology/precipitating
factor
S: Doenges, et. Al. Nurse’s Pocket
Guide 11 ed. F. A. Davis
Company. Pg. 500
I: obtain client’s assessment of
pain including location,
characteristic, onset, duration,
frequency, quality, intensity and
aggravating factor
R: to evaluate client’s response to
pain
S: Doenges, et. Al. Nurse’s Pocket
Guide 11 ed. F. A. Davis
Company. Pg. 500
I: accept clients description of pain
R: to evaluate client’s response to
pain
S: Doenges, et. Al. Nurse’s Pocket
Guide 11 ed. F. A. Davis
Company. Pg. 500
I: observe nonverbal cues and
behaviors
R: to evaluate client’s response to
pain
S: Doenges, et. Al. Nurse’s Pocket
Guide 11 ed. F. A. Davis
Company. Pg. 500
I: determine client’s acceptable
level of pain
R: to assist client to explore
methods for control of pain
S: Doenges, et. Al. Nurse’s Pocket
Guide 11 ed. F. A. Davis
Company. Pg. 500
I: provide comfort measures
R: to assist client to explore
methods for control of pain
S: Doenges, et. Al. Nurse’s Pocket
Guide 11 ed. F. A. Davis
Company. Pg. 501
I: instruct and encourage use of
relaxation techniques
R: to assist client to explore
methods for control of pain
S: Doenges, et. Al. Nurse’s Pocket
 Guide 11 ed. F. A. Davis
Company. Pg. 501
I: encourage verbalization of pain
R: to assist client to explore
methods for control of pain
S: Doenges, et. Al. Nurse’s Pocket
Guide 11 ed. F. A. Davis
Company. Pg. 501

Laboratory: Long Term Dependent

No laboratory results needed for nursing
intervention
Theoretical Basis:
A case of N.L. 56 yrs. Old, female married
admitted after being hit by a passenger bus,
with fracture of right arm, diagnosis of
After 3 days of nursing intervention, client will
be able to follow pharmacological regimen
I: administer analgesic medication
as ordered
R: to assist client to explore
methods for control of pain
S: Doenges, et. Al. Nurse’s Pocket
Guide 11 ed. F. A. Davis
Company. Pg. 501

Debridement and Possible Orif @ Right Arm , I: document/observe

R: to assist client to explore
with hypertension and diabetes
methods for control of pain
mellitus type II
S: Doenges, et. Al. Nurse’s Pocket
Fracture Guide 11 ed. F. A. Davis
Company. Pg. 501
Damage to tissues I: collaborate in treatment of
underlying condition causing pain
Inflammatory process R: to assist client to explore
methods for control of pain
Irritation to tissues S: Doenges, et. Al. Nurse’s Pocket
Guide 11 ed. F. A. Davis
Pain
 Company. Pg. 501
Pain is an unpleasant sensory and emotional
experience arising from actual or potential
tissue damage