Chapter IX NURSING CARE PLAN

DIAGNOSIS Acute pain r/t surgical incision as manifested by verbalization of perceived pain around the surgical site, and slight facial grimacing Cues: Subjective: >After operation, she verbalized, Akong tahi, nagasakit pa. >Felt pain around the surgical site >Believes that pain felt is due to postoperative experience Objective:

NEED

P H Y S I O L O G I C N E E D

DESIRED OUTCOME Within 8 hours of Nursing Interventions, >Manage Pain by following prescribed pharmacologic regimen and be relieved by nursing interventions >Take a rest and sleep

INTERVENTIONS INDEPENDENT Establish rapport to the patient Monitor vital signs frequently and interpret it accurately

RATIONALE

EVALUATION STATEMENT Goal Partially Met. Reduced complaint of pain Claimed that pain is already subsiding Was able to take rest periods

INTERVENTIONS Continue Nursing Interventions especially monitoring vital signs, assessing characteristics of pain, providing comfort measures, health teachings, and providing quiet environment and wellventilated area Administer analgesics as ordered/prescr ibed

RATIONALE To decrease pain felt To provide comfort To prevent fatigue To enhance self-image

To gain clients trust and cooperation

To see
trends including progress of condition or any unusual signs For accurate assessment of pain

Assess location, intensity, and aggravating factors at frequent interval by the patients selfreported pain Assess for behavioral and physiological responses to

For faster relief of pain

These are potential indicators of pain in

>Slight facial grimacing >Vital Signs: T=360 C PR=70 bpm RR=18 cpm BP=120/70 mmHg

pain

patients who are unable to self-report To provide comfort To prevent fatigue

Do bedside care Provide with rest intervals with quiet environment and wellventilated area Position comfortably

Background Knowledge: Most patients experience pain after a surgical procedure. Complete absence of pain in the area of the surgical incision may not occur for a few weeks, depending on the site and nature of the surgery, but the intensity of postoperative pain gradually subsides on subsequent

Provide comfort measures such as massaging of hands or back and by staying with the patient

To relieve discomfort caused by pressure and to improve circulation

To enhance
self-image and divert the attention of the patient

Render health
teachings which may be helpful after discharge such as not lifting heavy objects, To let patient manage condition in the most careful manner

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days. About 1/3 of patients report severe pain, 1/3 moderate pain, 1/3 little or no pain. They appear to activate psychodynami c mechanisms that impair the registering of pain (gate closing) theory and nociceptive transmission). Reference: Brunner & Suddarth. Textbook of Medical Surgical Nursing. Ed 12. Vol. 1

ambulate with assistance, proper wound dressing, hygienic care, and to report pain as soon as it begins Implement use of Range of Motion Exercises, and relaxation

To reduce
drug therapy as possible; however, these may add to the action of pharmacolog ic regimen

DEPENDENT Administer analgesics IVTT as prescribed

To have
quick time for onset of relieving pain, patient is for NPO

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DIAGNOSIS Fatigue r/t postoperative experience as manifested by evidence of weakness and deep sleep Cues: Objective: >After operation, patient is on bed rest >Flat on bed and shows evidence of weakness >Steady and in deep sleep for 4 hours >Vital Signs: T=360 C PR=70 bpm RR=18 cpm BP=120/70 mmHg

NEED

P H Y S I O L O G I C N E E D

DESIRED OUTCOME Within 8 hours of Nursing Interventions,

INTERVENTIONS INDEPENDENT Establish rapport to the patient Monitor vital signs frequently and interpret it accurately

RATIONALE

EVALUATION STATEMENT Goal Met. Was able to demonstrate improved level of energy by having rest periods Appeared relax and calm

INTERVENTIONS Retain Nursing Interventions

RATIONALE To continue progress of improving patients level of energy

>Demonstrate improved level of energy specifically to participate in therapeutic activities at level of ability

To gain clients trust and cooperation

To see
trends including progress of condition or any unusual signs

Cooperates
>Restore energy through rest intervals Provide with rest intervals with quiet environment and wellventilated area Provide comfort measures such as massaging of hands or back and by staying with the patient To prevent fatigue during administratio n of medication

To enhance self-image

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Background Knowledge:

Implement use of Range of Motion Exercises, and relaxation

Fatigue is
common after major surgery and delays recovery. It is usually attributed to the physiologic al response to surgery. Fatigue is a common health complaint. It is, however, one of the hardest terms to define, and a symptom of many different conditions. Fatigue, also known as weariness, tiredness, exhaustion or lethargy, is generally Provide patient with opportunities for expressing feelings of irritation, weakness, or discomfort Assist patient with setting and achieving goals Enhance patients power resources by fostering patient involvement in decision making by enabling patient to control environment as appropriate

To promote level of energy by conducting exercise and promoting circulation To let the patient feel you are concerned and shes not alone

To foster hope and bring back her liveliness For patients fast recovery and for her to gain confidence and enhance strength within self

Assess and

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defined as a feeling of exhaustion and decreased capacity for physical and mental work

motivate patients abilities to be an active participant in self-care

For the patient to recover as soon as possible

DEPENDENT Administer medicines as prescribed

Reference: http://www.emedici nehealth.com/fatigu e/article_em.htm December 23, 2010

To provide comfort to client as well as alleviate fear and anxiety

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DIAGNOSIS

NEED

DESIRED OUTCOME

INTERVENTIONS INDEPENDENT Establish rapport to the patient

RATIONALE

EVALUATION STATEMENT

INTERVENTIONS

RATIONALE

Altered comfort secondary to pain as manifested by frequent sighing and complaints of pain Cues: Objective: >Frequent sighing >Complaints of pain surrounding the surgical site >Can respond to stimuli verbally and physically with weakness noted >Vital Signs: T=360 C PR=70 bpm RR=18 cpm BP=120/70 mmHg

To gain clients trust and cooperation To see trends including progress of condition or any unusualities To provide coping stress to alleviate the fatigue felt by the client To prevent fatigue

Monitor vital signs frequently and interpret it accurately

Encourage diversional activity like listening to music Provide with rest intervals with quiet environment and wellventilated area Provide comfort measures such as massaging of hands or back and by staying with the patient Implement use of Range of Motion Exercises, and relaxation

Within 8 hours of Nursing Interventions,

To enhance self-image

Goal Met

Continue
providing comfort measures and rest intervals

The patient
was able to have a deep sleep for 4 hours

Background Knowledge:

Knowing 140
that someone you care about has just gone through surgery can make

P H Y S I O L O

>Enhance comfort by resting and sleeping

To bring back the patients energy loss and to restore proper body functions

Provide patient

To promote level of energy by conducting exercise and promoting circulation