NURSING CARE PLAN # 1

ASSESSMENT

Subjective
cues:

DIAGNOSIS
(NANDABASED)

PLANNING

Short term:

cues:

Incision in
the lower
abdomen
Guarding
Behavior
Facial
grimace
Positioning to
avoid pain

RATIONALE
(cite sources)

Acute Pain
r/t
to
Tissue Trauma After 3 hours of
- Dili na kaayo
Secondary to
nursing interventions:
sakit,
Status
Post
1. the client will
verbalized by
TAHBSO
(Total
state 3ways of
the patient.
Abdominal
- Pain Scale of
relieving pain
Hysterectomy
4 out of 10
such as
Bilateral Salphingo
imagery,
Oophorectomy)
application of
hot and cold
compress and
therapeutic
touch
2. the clients pain
scale will
decrease from
Objective
4 to 2.
-

IMPLEMENTATION

Long term:
At the end of 24
hours, patient will rate
pain as 0 out of 10

Independent
1. Instruct client to report any
improvement/exacerbation
in pain experience.
2. Encourage and assist client
to do deep breathing
exercises.
3. Encourage adequate
periods of rest and sleep,
including uninterrupted
periods of sufficient
duration, meeting comfort
needs, limiting/ avoiding
use of caffeine/ alcohol and
medications affecting REM
sleep. Encourage quiet,
restful atmosphere.
4. Discuss with relatives the
importance of early
detection and reporting of
changes in condition or any
unusual physical
discomforts/ changes.
5. Teach the client and
significant others about the
nonpharmacologic ways to
lessen pain.

EVALUATION
(ACTUAL)
Short term:

1. Unrelieved pain can create

other problems such as
anger, anxiety, immobility,
respiratory problems, and
delay in healing. (MedicalSurgical Nursing, 7th
ed. by Black, Joyce M. and
Jane Hokanson Hawks; p.
443
2. Deep breathing for relaxation
is easy to learn and
contributes to pain relief
and/or reduction by reducing
muscle tension and anxiety.
(Medical-Surgical Nursing, 7th
ed. by Black, Joyce M. and
Jane Hokanson Hawks; p.
479
3. To prevent fatigue. (Nurses
Pocket Guide, 9th ed. by
Doenges, Marilynn, et.al., p.
369)
4. Promotes early detection of
developing complications.
(Fundamentals of Nursing 7th
ed. by Kozier, Barbara, p.

Pain is reduced
controlled to a
tolerable extent
as verbalized.
Relieving
methods are
understood and
demonstrated,

Long term:

6. Increase intake of Vitamin

C
7. Monitor Vital signs

5.

Collaborative/Depende
nt:
8. Administer medications
(particularly analgesics) as
prescribed.
6.

7.

8.

536)
It may be possible to teach
clients a combination of
these techniques to
maximize their opportunities
for self-control over
manifestations of pain.
(Medical-Surgical Nursing, 7th
ed. by Black, Joyce M. and
Jane Hokanson Hawks; p.
476)
To promote healing of
wound. (Nutrition and Diet
Therapy by Peckenpaugh
page 328)
An information baseline
comparison from previous
data. (Manual of Nursing
Procedures Vol. I by
Locquiao, Cruz, Arguelles
and Lontoc page122)
Necessary for treatment of
the underlying cause.
(Nurses Pocket Guide, 9th
ed. by Doenges, Marilynn,
et.al., p. 542) To maintain
acceptable level of pain.
(Nurses Pocket Guide, 9th
ed. by Doenges, Marilynn,
et.al., p. 368)