Nursing Care Plan

Patient’s name: Leonila Araojo

Age: 45 years old Diagnosis: Acute pain

ASSESSMENT DIAGNOSIS INFERENCE GOAL INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Surgery in particular, SHORT TERM: INDEPENDENT: SHORT TERM:
“Masakit yung Acute pain produces biphasic insult on After 2 hours of nursing ♥ Provide comfort ♥ To promote After 2 hours of
opera ko” as related to tissue human body, which has intervention the client measures. nonpharmaco nursing intervention
patient verbalizes injury secondary implications for pain will be able to reduce logical pain The goal is met as
to surgical management. First of all, feeling of pain as management. evidenced by:
10 being the most intervention. during surgery there is manifested by: ♥ Instruct ♥ To destruct The patient verbalizes
painful she rate her trauma to tissue, which 1. Verbalization of in/encourage use of attention and reduced feeling of
pain as 8 produces noxious stimuli minimized or relaxation reduce pain. pain.
and great nociceptive controlled techniques.
OBJECTIVE: input. Secondly, after feeling of pain. ♥ Provide for ♥ To promote
o Surgical surgery there is 2. Pain scale individualized active, not
incision on inflammatory process at reduced from 8 physical passive, role LONG TERM:
hypogastric the site, which is also to 6. therapy/exercise and enhances
region. responsible for noxious program. sense of After 1 week of
o Positioning input. Both these processes LONG TERM: control. nursing intervention
to avoid sensitize the pain After 1 week of nursing the goal is met as
pain pathways. They occur at
intervention the client is evidenced by:
o grimacing free of pain on the The patient feels no
peripheral level where
upon perineum manifested by: DEPENDENT: pain upon doing light
there is a reduction in
making 1. Doing minimal ♥ Administer ♥ To maintain activities.
threshold of nocioceptive
even a activities with analgesics, as “acceptable”
afferents and at a central
slight ease and indicated. level of pain.
level with an increase in comfort.
movement.
excitation of spinal
neurons involved in pain
transmission.

Source:
http://medind.nic.in/iad/t06
/i5/iadt06i5p340.pdf
 Nursing Care Plan
Patient’s name: Leonila Araojo

Age: 45 years old Diagnosis: Acute pain