NURSING CARE PLAN (Post Op Exlap)
ASSESSMENT
Subjective: “Nanasakit po
yung opera ko sa tyan” as
verbalized by the patient.
Objective: Patient manifest
as weak and pale
appearance
difficulty in standing and
sitting- slowed movement-
limited range
Facial grimace and guarding
behavior
Pain scale 7/10
T = 36.5 ⁰C
P = 81 BPM
R = 20 BPM
BP = 110 / 90 mmHg
DIAGNOSIS
Impaired physical mobility
r/t post-op at midsagittal
incision wound at the
abdomen as manifested by
facial grimace, guarding
behavior limited motion and
pain scale 7 / 10.
PLANNING
After 8 hrs of nursing
intervention,the patient will
be able to report that the
pain is relieved that can be
evidenced by pain scale of
at least 0 - 2 / 10.
INTERVENTION
Independent: Provide quite
and comfortable /
therapeutic environment.
Encourage diversional
activities
Encourage adequate rest
wound care and change of
dressing
Discuss with relative ways in
which they can assist client
Dependent:
Administer due medication
RATIONALE EVALUATION
To promote relaxation and After 8 hours of of nursing
reduce tension intervention goals are
partially met.
The patient was slightly
relieved from pain as
To divert the attention of evidenced by the pain scale
patient from the pain of 5 / 10.
To prevent fatigue
To reduce avoid infection
To reduce precipitating
factor that may ease or
increase pain