NURSING CARE PLAN

PLANNING EVALUATION
NURSING GOAL / EXPECTED OUTCOME NURSING INTERVENTIONS
ASSESSMENT DIAGNOSIS

Subjective Pain, Acute; After 4 hours of nursing 1. Assessed reported or referred pain. After 4 hours of nursing
Sir “masakit ang ilalim ng related to intervention VR’s reported post- 2. Performed comprehensive assessment intervention, VR’s post-
labi ko” as verbalized by disruption of surgical incision pain will be of pain including location, surgical incision pain was
the patient. normal tissue controlled as evidenced by: onset/duration, frequency, quality and controlled as evidenced by:
integrity severity at 0-10 pain scale.
Pain scale reported at - Absence of antalgic behavior 3. Accepted clients description of pain. - Absence of antalgic behavior
9/10 - Absence of facial mask no sleep - Absence of facial mask and
4. Observed for non-verbal cues of pain.
disturbance no sleep disturbance
- Absence of expressive behaviors 5. Provided back-rub as non-
Objective - Absence of expressive
- with sub-labial post- - Displays no autonomic alteration pharmacologic measure for pain. behaviors
surgical incision wound in muscle tone 6. Monitored v/s. - Displays no autonomic
- guarded/protective - Absence of self-focusing behavior 7. Provided a calm and quiet environment. alteration in muscle tone
behavior - Pain scale reported rating at 1-3 8. Instructed to report pain as it occurs. - Absence of self-focusing
- with facial grimace categorized as mild pain 9. Instructed/encouraged deep breathing behavior
- restless and irritable exercises. - Pain scale reported at 1-3
- moaning to pain 10. Encouraged diversional activities such categorized as mild pain.
- flaccid as radio using a head set device.
- diaphoretic 11. Regulated Tramadol drip (300 mg Goal Met
- reduced interaction Tramadol + 234 cc PNSS) at 10 mcgtts/
minute as ordered.
VS taken as follows:
12. Administered Tramadol 25 mg IV for
RR: 28 breaths/ min
BP:160/110 mmhg breakthrough pain as ordered.
13. Continued to administer celcoxx 200mg,
1 cap BID post anesthesia order to lift
tramadol medication thru IV.