B.

Nursing Care Plan

ASSESSMEN T Subjective: Sumasakit pa nga yung tahi ko dito sa parteng niligate at sa cs ko Objective: Facial mask of pain (+) Guarding position while we are interviewing her. NURSING DIAGNOSIS Acute pain related to post-op surgical incision as evidenced by facial mask of pain. ANALYSIS The patient experiences pain because of the incision done to her after her CS and BTL operation. Pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage . (http://www.pai nmanagementinfo.com/definit ion-of-pain.htm) PLANNING GOAL After 8 hours of nursing intervention, the patients pain will be minimized. OBJECTIVES After 5 minutes, the client will verbalize the characteristic and location of pain. IMPLEMENTA TION RATIONALE EVALUATION The patients pain minimized.

Perform a comprehensiv e assessment of pain to include location, characteristic s, onset, duration, frequency, quality, intensity or severity, and precipitating factors of pain.

Pain is a subjective experience and must be described by the patient in order to plan effective treatment.

The patient was able to verbalize, to characterize and locate the pain.

After 10 minutes the client will be able to perform pain management like;

The use of noninvasive pain relief Teach the use measures that of noncan increase pharmacologic the release of techniques: endorphins Deep breathing and enhance technique the

The patient was able to perform deep breathing exercise.

 Deep breathing technique On the right time given, administer pain reliever to the client. Provide optimal pain reliever with doctors prescribed analgesics.

therapeutic effects of pain relief medications. Each client has a right to expect maximum pain relief. Optimal pain relief using analgesics includes determining the preferred route, drug, dosage, and frequency for each individual. Medications ordered on a prn basis should be offered to the client at the interval when the next dose is available.

The patient was able to take her due medications.

Monitor the patients vital

The patients vital signs

signs After every 4hours, the vital signs of the patient will be monitored. Assessment of vital signs is an important component of the physical therapy examination and should be included in the examination of all patients. Knowledge of vital signs allows the therapist to understand a patient's physiologic status and is helpful in determining appropriate goals

were monitored.