N256 Mini Care Plan

Nursing
Diagnoses
(NANDA)

Focus of
physical
assessment

Need more
information
from
patient/family/
Doctor about:

Top three
priorities
(goals) for
patient care
Nursing
Interventions

Teaching
needed/provide
d

Hana Scully

Expected
(Complete before assessment)

Found
(Complete after assessment)

1. Acute pain r/t surgical procedure aeb

patient verbalizes pain, guarding behavior,
tachycardia, pallor, and abdominal tenderness.
2. Altered bowel elimination r/t general
anesthesia and manipulation of bowel during
surgery aeb no BM or flatus, bowels sounds
hypoactive, nausea, abdominal distention.
3.Risk for infection r/t abdominal incisions
GI.
Abdomen soft and tender to touch, nondistended, possible BM, abdominal pain, pass,
tolerates liquid diet, bowel sounds
normoactive to auscultation. Nausea no
vomiting

1. Acute pain r/t surgical procedure aeb patient

verbalized pain a 5/10, patient guarding abdominal
area, and abdomen tender to touch. _
2. Altered bowel elimination r/t general anesthesia
and manipulation of bowel during surgery aeb no
BM, abdomen slightly distended, patient verbalized
feeling bloated.
3. Risk for infection r/t three abdominal incisions.
Abdomen soft and tender to touch slightly
distended. Post op day one from laparoscopic lysis
of adhesions. Las BM 10/10. Bowl sounds in all
four quadrants. Patient is passing flatus and
tolerating clear liquid diet. Verbalized abdominal
pain a 5/10. No nausea and vomiting

Last BM.
Duration, intensity, characteristics of pain.
Will a CMP test be done?
Interventions for low hgb, hct.
Are there and medications she is taking for
anxiety at home (possible anxiety in the
hospital)
Discharge orders from physician and follow
up appointment.

Last BM was on 10/10

Pain post op day 1 was chronic, throbbing, and rate
a 5/10.
No CMP ordered
No orders/interventions for low hgb, hct.
Patients takes clonazepam at home for anxiety
Discharge date 10/12, waiting for order and follow
up appointment date.

1.Manage pain
2.Pass flatus/ stool
3.Tolerate meals
1. Asses characters of pain, offer PRN pain
medication
2. Asses abdomen for distention, tenderness,
bowl sounds, passing stool, flatus, Administer
stool softeners & laxatives.
3.Asses incision dressing for
drainage/bleeding (free of s/s of infection)
4. _Ambulate out of bed TID
5. Incentive spirometer every hour

1. Patient education on pain management, to

control the pain and not wait for it to get too
severe before asking for pain medication.

1. Pain management, patient denied PRN pain

medication
2. Pass flatus/stool. Patient passes flatus, no BM
3. Free from infection. No fever, or s/s of infection
(Hemodynamic regulation
1. Assessed pain patient verbalized 5/10 chronic
throbbing abdominal pain. Denied prn pain
medication.
2.Assesed abdomen, soft, tender tot touch,
normoactive bowel sounds, and passing flatus, no
BM 10/10. Administered PRN stool softeners and
laxatives.
3. Assessed incision dressings no signs of bleeding
or infection. Mild scant serosangeous drainage on
old dressing.
4. _Patient out of bed and walking to bathroom and
around the room, steady gait.
5. Patient education on importance of incentive
spirometer, patient performed incentive spirometer
every hour. ___
1.Provided education on pain management, patient
needed teaching on not letting pain levels get to
high before asking for pain medication.

2.Patient education on stool softeners and

laxatives
3.Patient education incentive spirometer
4.Patient education on clear liquid diet post op
and advancing to a regular diet
5.Paitent education on ambulating
6.Patient education on s/s of infection to
report to the nurse
7.Patient education on discharge plans

Discharge
planning

Discharge planned for this afternoon 10/12 if

patient tolerates meals and is able to pass
flatus and pain is managed.

2. Providing teaching above stool softener

medications and importance of having a BM and
informing the nurse. Encouraged fluid intake to
promote BM.
3. Patient needed teaching on importance of
incentive spirometer and teaching provided on how
to use Incentive spirometer.
4. Provided teaching on importance of starting with
a liquid diet post op and advancing to a regular diet.
5. Patient was willing to get out of bed before
being asked to ambulate.
6. Provided teaching on s/s of infection to report to
the nurse/physician. Patient and spouse verbalized
symptoms and
Patient tolerated meals and was able to pass gas.
Patient was getting discharge orders as my shift
was ending.