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VI.

NURSING CARE PLAN


Problem #1
Acute Pain r/t irritation of nerve endings secondary to surgical procedure as evidenced by pain scale of 7/10
ASSESSMENT NURSING SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS EXPLANATION INTERVENTIONS
SUBJECTIVE: Acute pain r/t Acute pain is a Short Term:  Established -To gain patient’s Short Term:
 “Minsan irritation of type of pain that rapport trust and
sumasakit nerve endings typically lasts less After 8 hours of cooperation After 8 hours of
yung binti secondary to than 3 to 6 months nursing  Assess general - To evaluate nursing
ko” as surgical directly related to interventions, the condition client’s state interventions, the
verbalized procedure as soft tissue damage. patient will be able  Monitor and -To obtain baseline patient shall have
by the evidenced by It is of short to report that pain is record vital reported that pain is
patient pain scale of duration but relieved or signs relieved or
7/10 gradually resolves controlled  Provide rest and -To prevent stress controlled
OBJECTIVE: as the injured sleep periods
 Pain scale tissues heal. Long Term:  Provide comfort -To promote safety Long Term:
of 7/10 Reasons for pain measures
 Facial can be pinpointed After 2-3 days of  Encourage to -To assess client’s After 2-3 days of
grimace like trauma, nursing report any pain response to pain nursing
 Guarding surgery, acute interventions the or discomfort interventions the
medical conditions patient will be able - To promote non patient shall have
behavior  Encourage to do
or a physiological to demonstrate the pharmacological demonstrated the
relaxation
process and use of relaxation pain management use of relaxation
techniques such
responds well to techniques and -Helps to distract techniques and
as deep
conventional diversional attention and diversional
breathing
analgesia (opioids, activities for reduce tension. activities for
exercises
local anesthetics, individual situation. -To help determine individual situation.
 .Assess for
etc). possibility of
referred pain
underlying
condition
 Use pain rating -To evaluate
scale client’s response to
appropriate for pain
age and
condition
 Accepts client
description of -Pain is a subjective
pain experience
 Observe non-
verbal cues and -Observations may
pain behaviors not be congruent
 Monitor skin with verbal reports
color and -which are usually
temperature and altered in acute pain
vital signs
 Discuss with
SO ways in -Post-op patients is
which they can prohibited from
assist client and engaging in
reduce strenuous activities
precipitating because it
factors that may facilitates pain or
cause or fatigue.
increase pain
like
participating in
household
tasks.

 Advise patient
to eat foods that -For faster wound
are high in healing.
Vitamin C like
fruits and green
leafy
vegetables.

 Administer
analgesics as -to maintain
ordered acceptable level of
pain
Problem #2
Risk for Infection r/t post-operative wound
ASSESSMENT NURSING SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS EXPLANATION INTERVENTIONS
OBJECTIVE: Risk for Any broken skin After 8 hours of  Stress proper -Reduces risk Patient verbalizes
 presence of infection r/t or traumatized nursing hand, of the importance of
post- post- tissue like a post- interventions, the perineal and contamination general body
operative operative operative wound patient will be able daily oral and acquiring hygiene as well as
wound wound can serve as a to: hygiene. of HAIs as comply with the
portal of entry of well as other health teachings.
pathogenic  identify infections.
organisms. interventions
to prevent or  Demonstrate -Prevents
reduce risk proper contamination.
of infection; disposal of
 demonstrate contaminated
techniques materials.
and lifestyle
changes to  Encourage to -Nutritious
promote safe eat nutritious foods boost
environment; foods like the immune
and fruits, system for
 achieve vegetables, protection of
timely meat, poultry foreign bodies
wound and increase in the body.
healing. oral fluid
intake.

 Instruct -The
patient and environment is
SO to one of the
maintain a factors that
clean contribute to
environment. spread of
infection.
Problem #3
Risk for Injury r/t altered mobility
ASSESSMENT NURSING SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS EXPLANATION INTERVENTIONS
OBJECTIVE: Risk for Risk for injury can After 8 hours of  Perform -Failure to Patient verbalizes
 Left Leg Injury r/t result from nursing interventions, thorough accurately understanding of
Cast altered environmental the patient will be able assessment assess, factors that can
 Metal mobility conditions to: regarding intervene or contribute further
plating on interacting with patient's refer these injury and
left femur the individual's  verbalize safety issues can demonstrate ways to
 Loss of adaptive and understanding place the client reduce risk or
skeletal defensive of individual at risk and prevent this.
integrity resources. Any factors that create
(fracture) pathophysiological contribute to negligence.
condition such as possibility of
altered level of injury;  Maintain bed -To minimize
consciousness,  demonstrate in lowest the risk and
impaired sensory behaviors and position with degree of
perception, tissue lifestyle the wheels injury to the
hypoxia, and pain changes to locked and client.
or fatigue can reduce risk side rails up.
contribute to or be factors and
the cause of protect self  Monitor -To identify
personal injury. from injury; environment any unsafe
Age-related  modify for conditions to
factors include environment to potentially reduce the risk
infancy, early enhance safety; unsafe of injury
childhood and and conditions occurrence to
advanced age.  be free of and modify the client
further injury. as needed.

 Assist client -To minimize


in using the effort and
crutches or energy of the
wheelchairs. client when
leaving the
bed side and
for
ambulation.

 Assist the -The risk of


client when injury is
he needs to greatly
use the toilet increased
facility. when client is
left
unattended.