Colleen S.

De la Rosa
BSN III
NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Evaluation

NSG. Action Rationale
Subjective Acute pain r/t After the interventions After the shift and the
Data:Sumasakit ung post-op incision the patient will display 1. Note the 1. To help evaluate nursing intervention,
inoperahan sakin, reduction of pain from a location, time the place of
patient displayed reduction
kumikirot. As pain scale of 4-5 to 1-2 intensity scale (0- obstruction and
of pain from a scale of 5-6 to
verbalized by the 10) pain. cause pain.
0-1.
patient. 2. Monitor vital 2. It serves as a
signs. baseline data to
Objective Data: check if there are
- Pain scale of any deviations
5-6/10 from her vital
- Weaken signs.
- Irritable 3. Encouraged and 3. Deep breathing
assist client to do exercises
- Grimace
deep breathing contribute to relief
- With dry skin exercises of pain
turgor 4. Provide 4. For clients
- Temp: 36.5 diversional comfort and relief
- BP: 100/70 activities like from pain
- RR: 22 socialization
- PR: 82 5. Provide 5. To reduce pain
adequate rest and promote
relief/comfort
6. Administer 6. To maintain
analgesics to acceptable level of
reduce pain. pain.