NURSING CARE PLAN

GOALS/
CUES/ ASSESSMENT NURSING NURSING
RATIONALE EXPECTED RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
OUTCOMES

Subjective data: Acute pain secondary to Hysterectomy After 8 hours of INDEPENDENT: After 8º of rendering
surgical procedure ↓ rendering nursing nursing care, the goals
The patient verbalizes: (hysterectomy) as Breaking in the 1. Evaluate pain regularly 1. Provide information was met partially as
intervention, the
evidence by reported noting characteristic, about need for or evidenced by:
continuity of the skin patient will be able to:
“I felt pain on my pain with the pain scale location intensity (0-10). effectiveness of
of 8 (pain scale from 1 ↓ intervention.  Decreased
surgical incision”
– 10), limited range of Imflamation process pain scale to the
 Decrease pain
Objective data: motion and sleep triggered 2. Identify specific 2. Prevents undue strain level of 5.
scale of 8 to 4 as
disturbance pattern ↓ activity limitations. on operative site.
evidence by
 Reported pain Nerve ending stable vital signs.
with the pain scale 3. Reposition as indicated. 3. May relieve pain and
compression
of 8 (pain scale enhance circulation
from 1 – 10) ↓
 Facial Pain 4. Encourage of relaxation 4. Relieves muscle and
grimacing technique like deep emotional tension.
 Guarding breathing exercise.
behavior
5. Monitor vital signs 5. Changes in vital signs
may be used for rough
estimate of pain.

DEPENDENT: DEPENDENT:

1. Administer analgesic 1. To relieve mild or

medication: Ketorolac moderate pain.
IVTT x 4 doses q 8 hours
as prescribe by the
physician.