NURSING CARE PLAN # 1

ASSESSMENT

DIAGNOSIS

PLANNING

IMPLEMENTATION

(NANDA-BASED)
Subjective cues:
-

Acute Pain

sakit,

r/t to Tissue

verbalized by

Trauma Secondary

the patient.
Pain Scale of

to Status Post

6 out of 10

TAHBSO (Total
Abdominal
Hysterectomy
Bilateral Salphingo

Objective cues:
-

Incision on the
lower

abdomen
Guarding

Behavior
Facial grimace
Positioning to
avoid pain

(cite sources)
Short term:

Dili na kaayo

Oophorectomy)

RATIONALE

Independent

EVALUATION
(ACTUAL)
Short term:
Pain is reduced

After 3 hours of

1. Instruct client to report

1. Unrelieved pain can create

controlled to a

nursing

any

other problems such as anger,

tolerable extent

interventions:

improvement/exacerbatio

anxiety, immobility, respiratory

as verbalized.

1. the client will

state 3ways
of relieving
pain such as
imagery,
application of
hot and cold
compress and
therapeutic
touch
2. the clients
pain scale will
decrease
from 4 to 2.

n in pain experience.
2. Encourage and assist
client to do deep
breathing exercises.
3. Encourage adequate
periods of rest and sleep,
including uninterrupted
periods of sufficient
duration, meeting comfort
needs, limiting/ avoiding
use of caffeine/ alcohol
and medications affecting
REM sleep. Encourage
quiet, restful atmosphere.
4. Discuss with relatives the
importance of early
detection and reporting of
changes in condition or

problems, and delay in healing.

2. Deep breathing for relaxation is
easy to learn and contributes to
pain relief and/or reduction by

Relieving
methods are
understood and
demonstrated,

reducing muscle tension and

anxiety.
3. To prevent fatigue.
4. Promotes early detection of
developing complications.
5. It may be possible to teach

Long term:
Goal partially
met. Patient was
able to control
pain.

clients a combination of these

techniques to maximize their
opportunities for self-control
over manifestations of pain.
6. To promote healing of wound.
7. An information baseline
comparison from previous data.
8. Necessary for treatment of the
underlying cause. To maintain
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Long term:

any unusual physical

acceptable level of pain.

discomforts/ changes.
At the end of 24

5. Teach the client and

hours, patient will

significant others about

rate pain as 0 out of

the nonpharmacologic

10

ways to lessen pain.

6. Increase intake
of Vitamin C
7. Monitor Vital signs
Collaborative/Dependent:
8. Administer medications
(particularly analgesics)
as prescribed.

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