REPUBLIC OF THE PHILIPPINES

UNIVERSITY OF NORTHERN PHILIPPINES

TAMAG, VIGAN CITY
2700 ILOCOS SUR
COLLEGE OF NURSING
Student Nurse: Marinel F. Rafin

NURSING CARE PLAN 1

NURSING SCIENTIFIC NURSING
ASSESSMENT GOAL/OBJECTIVE RATIONALE EVALUATION
DIAGNOSIS BACKGROUND INTERVENTION

Subjective: Acute pain related Pain is a negative Short Term Goal: Independent: Short Term Goal:
 Patient’s to presence of factor that After 1-2 hours of 1. Monitored Vital -Establishes After 1-2 hours of
verbalization of surgical incision seriously affects a nursing interventions, signs. baseline data for nursing
pain on the secondary to patient's  The patient will reviews of interventions,
surgical site with Appendectomy as postoperative cooperate and existing  The patient
a pain scale of evidenced by recovery. Surgical establish measures conditions. cooperated in
8/10. facial grimace and trauma can to minimize pain establishing
patient’s activate peripheral such as the use of 2. Reassessed the -Bleeding on the measures to
verbalization of and visceral appropriate surgical site for the surgical site may minimize pain.
Objective: pain with pain nociceptors to diversional presence of suggest bigger
 Facial grimace scale of 8/10. induce central pain activities and bleeding. problems.  The patient
 Restlessness sensory nerve relaxation skills. manifested
 Irritability sensitization and 3. Applied ice packs -Ice stimulates the reduced pain as
 Guarding peripheral sensory  The patient will on the surgical site, non-pain evidenced by
behavior nerve conduction manifest reduction checked if receptors in the decreased pain
 Discomfort enhancement, in pain as contraindicated or same receptor scale from 8/10
leading to a evidenced by not. fields as the to 2/10 as
decreased decreased pain injury. tolerated by the
VS threshold for those scale from 8/10 to patient and
BP - 120/70 receptors and an 3/10 and below as 4. Encouraged patient -Patient may forget absence of facial
mmHg over-threshold tolerated by the to divert attention about the pain she grimace and
PR- 86 bpm response patient and absence by encouraging her is suffering thus, discomfort.
RR – 21 cpm enhancement, of facial grimace to tell a story. decreasing the
TEMP. - 37.2oC which is called and discomfort. pain.
 hyperalgesia. At
the same time, -May help in
tissue damage Long Term Goal: decreasing Long Term Goal:
caused by surgical After 3-5 days of 5. Encouraged the anxiety and After 3-5 days of
trauma can further nursing interventions, patient to express tension. nursing
lead to the the patient will her feelings with interventions, the
generation and remain free from regards to the pain patient remained
aggregation of complications that she is suffering. -This may promote free from
inflammatory could alleviate by comfort and complications.
mediators and stress due to the 6. Encouraged patient enhance sense of
pain-related presence of pain on to perform well-being. GOAL MET
factors, further the surgical site. relaxation
aggravating pain. techniques.
Provided -Encourages use of
therapeutic touch. pain relief
strategies familiar
7. Identified and to and accepted
encouraged patient by patient.
to use strategies
that have been
successful with -Permits assessment
previous pain. of effectiveness
of the
8. Reassessed for pain interventions
severity and given and
intensity. Use pain identifies needs
scale as needed. for further action
if ineffective.

- prostaglandin
synthesis by
Dependent: competitive
1. Administered blocking of the
Ketorolac 30 enzyme
 mg IV as cyclooxygenase
ordered. (COX) thus
reducing
swelling on the
incision site,
pain, or fever.

- Binds to mu-
opioid receptors.
Inhibits reuptake
2. Administered of serotonin and
Tramadol 50 norepinephrine
mg IV as in the CNS thus
ordered. decreasing pain

DRUG STUDY
Name and Dose, Frequency, Mechanism of Indications Contraindications Adverse Effects Nursing Responsibilities
Classification Route, Duration Action
 of Drug of Administration

Dose: Binds to mu-  It is used  Depression  dizziness.  Assess for pain scale
TRAMADOL 50 mg opioid for ease of  Patient with  headache. before and after
receptors. Moderate- decreased  drowsiness. administration.
opioid Route: Inhibits to- function of the  nausea and 
analgesics Intravenous reuptake of moderately adrenal glands vomiting.  Monitor consciousness
serotonin and severe pain.  Seizure  constipation. and mental status.
Duration: norepinephrine  Patient with  lack of  Guard against falls and
PRN in the CNS decrease lung energy. trauma (hip fractures,
thus decreasing function head injury). Implement
 sweating.
pain  Hypersensitivity fall-prevention strategies
 dry mouth.
with tramadol especially if patient
 Asthma exhibits sedation,
dizziness, or blurred
vision.
 Maintain patient on bed,
ensure patient’s safety by
raising side rails.
 Implement appropriate
manual therapy
techniques, physical
agents, and therapeutic
exercises to reduce pain
and help wean patient off
centrally acting
analgesics as soon as
possible.

DRUG STUDY
 Name and Dose, Frequency,
Mechanism of Nursing
Classification Route, Duration Indications Contraindications Adverse Effects
Action Responsibilities
of Drug of Administration

It acts on the  It is used in  Ketorolac ANST  headache  Administer skin test

KETOROLAC Dose: inhibition of post (+).  dizziness prior to giving the
10 mg prostaglandin surgeries  drowsiness medication, do not
synthesis by as a short- Use cautiously in:  diarrhea administer if a positive
Analgesic Route: competitive term  Breastfeeding  constipation reaction on the skin
Intravenous blocking of the treatment mothers.  gas test site occurs.
enzyme for pain.  History of GI  Monitor BP, notify the
 sores in the
Frequency: cyclooxygenase bleeding physician if it is less
mouth
Every 6 hours (COX) thus  Renal impairment than 90/80 mmHg.
 sweating
reducing  Cardiovascular  Assess for pain
Duration: swelling on the  bleeding
disease. location, intensity and
24 hours incision site,  altered
duration 1 hour before
pain, or fever.  hemostasis
after administration to
 allergic determine
reactions effectiveness of the
 renal damage. drug.
 Do not prolong the use
of ketorolac up to five
days as it may cause
severe bleeding.
 Note for signs of
allergic reactions such
as skin rash, coughing
and itchy sites.
 DRUG STUDY
Dose,
Name and Frequency,
Mechanism of Adverse Nursing
Classification Route, Indications Contraindications
Action Effects Responsibilities
Of Drug Duration of
Administration

During surgery, In surgery such  Cefuroxime  vomiting.  Administer skin test

CEFUROXIM Dose: cefuroxime is use as ANST (+)  nausea prior to giving the
E 750 mg as prophylactic appendectomy, it  cephalosporin  diarrhea. medication, do not
antibiotic and it is indicated hypersensitivity;  bloating administer if a positive
Route: can also be used mainly for:  or cephamycin and reaction on the skin test
Anti-infectives Intravenous post-surgery and it  Perioperative hypersensitivity. indigestion. site occurs.
Antibiotic works by binding prophylaxis  hypersensitivity  abdominal  Instruct patient that she
Frequency to specific (IV). to penicillin. pain. may experience these
Every 8 hours penicillin-binding To prevent:  loss of side effects: Stomach
proteins (PBPs)  Post-operative appetite. upset or diarrhea.
located inside the wound  Monitor signs of
bacterial cell wall, infection allergic reactions and
it inhibits the third  Skin and skin anaphylaxis, including
and last stage of structure pulmonary symptoms
bacterial cell wall infection. such as tightness in the
synthesis, thus throat and chest,
inhibiting wheezing, cough
biosynthesis and dyspnea.
arresting cell wall  Notify the physician if
assembly resulting signs of anaphylactic
in bacterial cell occurs.
death.  Discontinue if
hypersensitivity
reaction occurs.