NURSING CARE PLAN - Acute Pain

Assessment
S> Masakit pa din yung sa may lower body ko. S> Minsan wala akong ganang kumain. Kumikirot pa kasi. S> Pain scale of 7/10 O> Elevated vital signs BP 140/90 PR 103 bpm RR 32 cpm T 38.1C

NURSING DIAGNOSIS Acute pain related to physical injuring agents (Dilatation and Curettage)

GOALS NURSING RATIONALE INFERENCE AND INTERVENTIONS OBJECTIVES Unpleasant GOAL: Independent: sensory and After all To rule out Perform pain emotional nursing assessment each time worsening of experience intervention, the underlying pain occurs arising from client will report condition/dev actual or that pain is elopment of potential tissue relieved/ complications damage or controlled. described in Accept patients terms of such OBJECTIVES: Pain is a description or pain damage; sudden 1. After 10 subjective or slow onset of minutes of experience any intensity nursing and cannot be from mild to intervention, felt by others Observe for nonsevere with an the client will verbal cues anticipated or be able to: predictable end Pain is a and a duration - report pain subjective of 6 months. when it occurs. Monitor vital signs experience and cannot be Source: felt by others th NANDA 11 Provide quiet ed., pp. 498 environment -describe the

EVALUATION

1.

After 10 minutes of nursing intervention, the client was able to: - report pain as it occurred.

-describe the pain as it occurred.

O> Positioning to avoid pain O> Guarding behavior O> Facial Grimace O> Slightly irritable

pain as it occurs. 2. After 15 minutes of nursing intervention, the client will be able to verbalize methods that provide relief.

Provide comfort measures like back rub and change of position

It is usually altered by acute pain Promotes relaxation

2.

After 15 minutes of nursing intervention, the client was able to verbalize methods that provide relief.

After 15 minutes of nursing intervention, To assist in the client will muscle and be able to generalized demonstrate relaxation use of relaxation skills Prevents and diversional Dependent: boredom and activities. Administer enhances analgesics as needed. coping Notify the physician abilities 4. After the
3.

To provide 3. After 15 non Assist client to learn minutes of nursing pharmacologi breathing techniques intervention, the cal pain client was able to management demonstrate use of Encourage client to relaxation skills watch TV, listen to and diversional the radio, or socialize activities with others

4. After the shift, the prescribed pharmacological regimen to alleviate were all carried out.

shift, the prescribed pharmacologic al regimen to alleviate pain must all be carried out.

if regimen is inadequate to meet pain control goal

Administer analgesics as needed. Notify the physician if regimen is inadequate to meet pain control goal

NURSING CARE PLAN - Knowledge Deficient Assessment SUBJECTIVE: Dalawang araw na ako dinudugo, hindi ko alam ang gagawin ko (I am bleeding for the past two days, what should I do?) as verbalized by the patient. OBJECTIVE: onfusion C Request for information. Fear V/S taken as follows: T: 37.4 P: 75 R: 22 BP: 100/70 Diagnosis Knowledge deficient regarding condition, prognosis, treatment, self care, and discharge needs related to unfamiliarity with information resources. Inference Planning Dilatation and After 8 hours curettage, also of called as D&C, nursing is interventions a common , the surgical patient will procedure identify done on women relationship to scrape and of collect the tissue signs and from inside the symptoms uterus. The related cervical passage to surgical in a women procedure leads and to the uterus. actions to Dilatation is a deal widening of the with them. cervical passage. This is done using smoothly conical and tapered, graduated metal rods of various Intervention eview effects of R surgical procedure and future expectations. Discuss resumption of activity. Encourage light activities initially, with frequent rest periods and increasing activities or exercise as tolerated. Identify individual restriction like avoiding heavy lifting and strenuous activities. Identify dietary needs like high protein and additional iron. Rationale Provides knowledge base from which patient can make informed choices. Client can expect to feel tired when she goes home and needs to plan a gradual resumption of activities. Strenuous activity intensifies fatigue and may delay healing. Facilitates healing or tissue regeneration and helps anemia if present. Facilitate competent selfcare, promoting independence. Evalation After 8 hours of nursing interventions, the patient was able to identify relationship of signs and symptoms related to surgical procedure and actions to deal with them.

sizes and these are appropriately called the dilators. The gradually large metal dilators lead to widening of the tight cervical passage slowly. Curettage ("C") is the second part of the procedure and is done to scrape

Review incisional care when appropriate.

ULTRASOUND REPORT
Referring physician: Dr. C Others Cervix: 4.5 x 5.0 x 3.8 cm Endometrium: 1.3 cm Uterus: 6.3 x 6.0 x 5.4 cm Right Ovary: 2.7 x 2.9 cm (+) Corpus Luteum Left Ovary: 3.7 x 1.6 cm

Transvaginal scan shows normal sited cervix with a gestational sac of approximately 4 weeks 1 day age of gestation by mean-sac-diameter noted at the upper endocervical canal suggestive of abortion in progress. The uterus is slightly enlarged, anteversed with no myometrial lesion. The endometrium is thickened at 1.3cm with heterogeneous echoes within considered retained products of conception. Both ovaries are normal in site and echotexture with corpus luteum on the right (-) free fluid I the cul de sac.

Final Impression: Normal sized cervix with abortion in progress, slightly enlarged, anteverted uterus, thickened endometrium with RPOC. Normal ovaries, no adnexal pathology.

DOCTORS ORDER (COURSE IN THE HOSPITAL)

12 nn NPO (Preparation for D and C) VS q 30 minutes (To monitor closely any changes or unusualities in vital sign) Attach CBC, BT (CBC- To use as a basic information identify patients problem) (BT- because patient is prone to bleeding U/A (To detect substance or cellular material in the urine) IVF: D5LR + 10 u oxytocin @ 20 gtts/min Cefuroxime 1.5g IVTT start now

2:15 pm NPO (To allow for the affected organ to rest) VS q 30 minutes (To monitor closely any changes or unusualities in vital sign) IVF D5LR + 10 units of Oxytocin @ 30 gtts/min (D5LR-To support electrolytes in the body) TF D5NM 1L @ 30 gtts/min (D5LR-To support electrolytes in the body) DAT when fully awake Cefuroxime 750 mg q8 hr IVTT x2 doses Clindamycin 300mg 1cap q12hours MEM 1 tab q8hours MFA 500mg 1cap q8hours Iron 1cap q 12hours

Medication Instruct client to follow and take medication prescribed by the physician R: Treatment regimen is important to have faster recovery. Explain to the client the nature of the drugs so as the prescription. R: Knowledge about the medication will make the client aware of what she is taking and may increase her cooperation. Treatment:

Cefuroxime 750mg IV every 8 hours ANST (-) x 2 doses Iron 1 cap every 12 hours Clindamycin 300mg 1cap every 12 hours MEM 1tab every 8 hours MFA 500mg 1cap every 8 hours x 4 doses

Exercise Encourage to do early ambulation with resumption of normal activity as tolerated. R: Circulation of blood is promoted through regular movement thus help in healing process.

Advise client to take adequate rest and sleep. R: To gain back the lost strength and be able to return to its normal state thus allow ample time for healing.

Treatment: Explain to the client and family the need for treatment and that it is long process depending on the compliance of the client to the therapeutic regimen. R: To make the client and the family aware to the treatment does not end in the hospital and that their participation is a must in continuation of care. Encourage family member to provide patient emotional support.

R: To lessen anxiety and stress felt by the patient.