Far Eastern University

Institute of Nursing
First Semester 2010-2011

NURSING CARE PLAN

(Pain and Surgery)

Submitted by:
Abenir, Catherine P.
Abrillo, Theresa Noelle Jade
Acido, Linnette J.
Arenzana, Alyssa Mae M.
Balayan, Cathy Rose S.
Bautista, Grace M.
Caña, Niel Raymund G.
Cruzada, Dexter G
Dacanay, Danesse M.
Dano, Denise Ira D.
De Claro, Kimberly Ann V.
Dela Cruz, Danna Jastine S.

BSN214

Submitted to:
Ms. Zhenya Lim, RN MAN

August 14, 2010

NURSING CARE PLAN

NURSING ANALYSIS GOAL/OBJECTIVES NURSING RATIONALE EVALUATION

DIAGNOSES/CUES INTERVENTIONS
Acute pain related GOAL:
to tissue injury as After 1 day of Was the client relieved
manifested by nursing intervention, from pain?
verbal report of pain the client will be __Yes __No
relieved from pain Why:_______________
CUES: through
pharmacological and
Subjective: non-pharmacological
There was a methods
vehicular accident
and a tricycle OBJECTIVES: Discuss about: Effective pain Was the client able to
passed over her big After 10 minutes of 1. Balanced reduction and/or correctly enumerate
toe on her left foot discussion, the client analgesia – most relief is achieved and discuss 4 out of 6
will be able to frequently used through the pharmacological
Half of the nail was correctly enumerate means of pain combination of both management to relieve
already injured and and discuss 4 out of control. They are pharmaceutical and pain?
removed so the 6 pharmacological most commonly non-pharmaceutical __Yes __No
doctor told her that management to prescribed and can therapies. et.al. Why:_______________
the remaining nail relieve pain. be bought over the (2005).Medical
should also be counter. Surgical Nursing.
removed because 2. Patient control 7th Edition.Elsevier
there is a great risk analgesia (PCA) – PTE LTD.p459..
for infection and a machine wherein
tissue ischemia. the client has a
control over the
From a scale of 1 to drug administration.
10: 10 being the It has a lock system
highest and 1 the which automatically
lowest, the client locks when the
rated her pain machine detected
perception as being an overdose.
6. The client said, 3. Local anesthetic
“Sumasakit siya pag agent – causes loss
nilalakad pero mejo of feeling and
nawawala siya pag sensation.
nakahiga o 4. Opioids or
nagpapahinga lang narcotic analgesia
kaya dahan-dahan – only given when
lang ako there is moderate
naglalakad”. to severe pain. It is
related to many
Location: left big toe adverse effects and
should be taken
Duration of pain: 2 cautiously. Not
weeks over-the-counter
drugs.
Characteristics of 5. Non-steroidal
pain: sharp pain anti-inflammatory
(“Parang tinutusok drugs (NSAIDS) –
ng karayom”, as the for mild to
client verbalized.) moderate pain.
Helpful in reducing
Aggravating factor: pain associated
walking with cancer and
post operation.
Alleviating factor: *These are just the
resting most common pain
medications given
Radiation: none to clients.
Black, et.al.
Treatment: (2005).Medical
- Antibiotic () – 500 Surgical Nursing.
mg, thrice a day, for 7th Edition.Elsevier
2 weeks PTE LTD.pp459-
476.
- Changed to
amoxicillin 500 mg, After 10 minutes of Discuss about: Effective pain Was the client able to
twice a day, for 1 discussion, the client 1. Cutaneous reduction and/or correctly enumerate
week will be able to stimulation – a form relief is achieved and discuss 7 out of 12
- Tramadol – 500 correctly enumerate of distraction through the non-invasive non-
mg, thrice a day for and discuss 7 out of because the client combination of both pharmacological
1 week 12 non-invasive non- may focus on the pharmaceutical and management to relieve
management to sensation being non-pharmaceutical pain?
-Changed to to
relieve pain created rather than therapies. et.al. __Yes __No
mefenamic – 500 the pain (e.g. (2005).Medical Why:_______________
mg, twice a day for massage, Surgical Nursing.
1 week accupuncture). 7th Edition.Elsevier
2. Transcutaneous PTE LTD.p459..
-Vitamin C
Electric Nerve
(ascorbic acid) – Stumulation
500 mg once a day (TENS) – delivers
for 1 month electrical bursts
-Oxygen Peroxide – through the skin or
three times a day superficial and
for 1 month deep nerves. For
clients with chronic
-Providone iodine –
pain e.g muscle
three times a day pain and arthritis.
for 1 month 3. Deep breathing
or relaxation –
She has no known reduces muscle
drug allergies. tension and
anxiety.
She removed the 4. Heat and cold
gauze pad 3 weeks application –
after the surgery. prevents or reduces
edema and
She had nausea inflammation.
and vomiting, loss 5. Distraction –
of appetite and attention is directed
sleepiness and away from the
according to her painful sensation pr
doctor, it was a side the negative
effect of the emotional arousal
Tramadol so the associated with the
doctor changed her pain episode
Pain medication to through audiotapes,
mefenamic acid. craft activities and
interaction with
The client people.
verbalized, “Sabi 6. Guided Imagery
ngdoktor ko, ‘wag – helps a client
visualize a pleasant
ko daw muna iapak experience.
ng isang lingo then 7. Hypnosis –
after 1 week ko pa based on
lang pwedeng suggestion,
ilakad ulit para unti- dissociation, and
unti na akong the process of
makalad ng focusing attention.
maayos”. 8. Humor –
increases the
She does not number of Natural
engage herself in Killer (NK) cells of
non- the immune
pharmacological system.
methods of 9. Biofeedback –
reducing pain purpose is to reach
self-control over
The client physiologic
verbalized, “Minsan variables that relate
nakakaligtaan kong to the pain by
inumin mga gamut providing the client
ko sa tamang oras”. with information
about changes in
According to client bodily function.
she sometimes get 10. Magnets – The
irritated when in pull of magnet
pain. increases blood
flow to the region,
opening the sodium
Objective: and chloride
The surgery site is channels in the
located on the big cells.
toe of the left foot. 11. Music therapy –
provides distraction
The surgery site is and dissociation by
inflamed, warm to focusing on the
touch and there is characteristics of
bluish discoloration the music
around the area. selection.. It also
releases
The size of the endogenous
open wound is opioids.
approximately 1 12. therapeutic
inch in diameter. touch – pain
management use
There are 5 stitches for tension
in the wound. headaches.
Black, et.al.
There is a growing (2005).Medical
nail of about 1 cm in Surgical Nursing.
length. 7th Edition.Elsevier
PTE LTD.p476-
There are no 480.
purulent drainage
and foul smelling After 5 minutes of Non- To avoid the Was the client able to
odor present. discussion, the client pharmacological adverse effects of state the importance of
will be able to state pain management some pain including non-
Walks with the importance of is important medications can pharmacological
crutches. Has including non- because: bring. It also brings methods of pain
difficulty in walking pharmacological - It adjuncts pain more effectiveness management?
methods of pain reduction and/or in the reduction of __Yes __No
Temp: 36.8˚C management. relief. pain. Why:_______________
PR: 78 bpm -It is useful while Black, et.al.
RR: 17 cpm the client is waiting (2005).Medical
BP: 120/80 for medications to Surgical Nursing.
take effect. 7th Edition.Elsevier
-there are clients PTE LTD.p459-
whose major 460.
concerns are the
medication’s side
effect might cause
problems in
medication
administration.
Black, et.al.
(2005).Medical
Surgical Nursing.
7th Edition.Elsevier
PTE LTD.p459.
After 20 minutes of Pain medications Overuse of certain Was the client and/or
discussion, the client should be given at drugs may lead to SOs able to
and/or SOs will be a specific time.and overdose and drug demonstrate proper
able to demonstrate during a given span addiction. administration of pain
proper administration time with the Black, et.al. medications based on
of pain medications adequate dosage (2005).Medical client’s needs?
based on client’s based on client’s Surgical Nursing7th __Yes __No
needs. age. Clients should Edition..Elsevier Why:_______________
have a list where PTE LTD.p444.
the dosage and the
time is indicated to
avoid lapses in
administration.
Black, et.al.
(2005).Medical
Surgical Nursing.
7th Edition.Elsevier
PTE LTD.pp459-
476.

After 30 minutes of Discuss the step by To manage pain Was the client able to
demonstration, the step procedure of and promote demonstrate the proper
client will be able to deep breathing healthy living. way of deep breathing
demonstrate the exercise: Black, et.al. exercise?
proper way of deep 1. Ask the client to (2005).Medical __Yes __No
breathing exercise. clench his fist while Surgical Nursing.7th Why:_______________
taking a deep Edition.Elsevier
breath PTE LTD.pp459-
2. Ask the client to 476.
hold his breath for a
moment, and
exhales wile letting
oneself “go limp”
3. The cycle is
followed by a slow,
deep breath
mimicking a yawn.
Black, et.al.
 (2005).Medical
Surgical Nursing.7th
Edition.Elsevier
PTE LTD.pp459-
479.

After 15 minutes of Discuss with the To make the client Was the client able to
discussion, the client client that aware of the impact verbalize the
will be able to unrelieved acute of pain on lifestyle importance of his/her
verbalize the pain leads to and independence. collaboration with the
importance of his/her debilitation, Doenges, et. al, treatment procedures?
collaboration with the diminished quality (2008). Nurse’s __Yes __No
treatment of life, and Pocket Guide. 11th Why:_______________
procedures. depression. Edition. F.A. Davis
Unrelieved acute Company. p. 502.
postoperative pain
leads to
development of
chronic pain
syndromes and
increased
complications. In
fact, unrelieved
pain can kill.
Black, et.al.
(2005).Medical
Surgical Nursing.7th
Edition.Elsevier
PTE LTD.p440.
Were resources
available to the nurse
and client maximized?
_ yes _no
Why: ______________

Were interventions
appropriate to the
client’s age and health
condition?
_ yes _no
Why: _____________

Were all interventions

acceptable to the
client’s beliefs and
values?
_ yes _no
Why: ____________

Was the number of

interventions enough to
solve the current
problem?
_ yes _no
Why:_____________