Chapter IX
NURSING CARE PLAN
DESIRED EVALUATION
DIAGNOSIS NEED INTERVENTIONS RATIONALE INTERVENTIONS RATIONALE
OUTCOME STATEMENT
Acute pain r/t Within 8 hours of INDEPENDENT Goal Partially Met.
surgical incision as
P Nursing
Continue
Nursing
To decrease
pain felt
manifested by H Interventions, Establish To gain Reduced Interventions
verbalization of rapport to the client’s trust complaint of especially To provide
perceived pain Y >Manage Pain patient and pain monitoring comfort
around the surgical S by following cooperation vital signs,
site, and slight prescribed assessing To prevent
facial grimacing I pharmacologic Monitor vital To see
Claimed that
pain is characteristics fatigue
regimen and be
O relieved by
signs
frequently and
trends already of pain,
providing
including subsiding To enhance
Cues: L nursing interpret it progress of comfort self-image
interventions accurately measures,
Subjective: O condition or
any unusual
Was able to
health
take rest
>After operation,
G >Take a rest and
signs periods
teachings, and
providing quiet
she verbalized, I sleep Assess For accurate environment
“Akong tahi,
nagasakit pa.”
C location, assessment and well-
ventilated area
intensity, and of pain
aggravating
>Felt pain around factors at
the surgical site frequent Administer
>Believes that pain
N interval by the analgesics as For faster
patient’s self- ordered/prescr relief of pain
felt is due to post- E reported pain ibed
operative
experience
E
Assess for These are
D behavioral and potential
Objective: physiological indicators of
responses to pain in
>Slight facial pain patients who
grimacing are unable to
self-report
>Vital Signs: Do bedside
care To provide
T=360 C comfort
PR=70 bpm Provide with
RR=18 cpm rest intervals To prevent
BP=120/70 with quiet fatigue
mmHg environment
and well-
ventilated area
Position
Background comfortably
Knowledge: To relieve
discomfort
Most patients caused by
experience pressure and
pain after a to improve
surgical Provide circulation
procedure. comfort
Complete measures To enhance
absence of such as self-image
pain in the massaging of and divert
area of the hands or back the attention
surgical and by staying of the patient
incision may with the
not occur for a patient
few weeks,
depending on
Render health
the site and
teachings
nature of the To let patient
which may be
surgery, but manage
helpful after
the intensity of condition in
discharge
postoperative the most
such as not
pain gradually careful
lifting heavy
subsides on manner
objects,
subsequent
135
ambulate with
assistance,
days. About proper wound
1/3 of patients dressing,
report severe hygienic care,
pain, 1/3 and to report
moderate pain, pain as soon
1/3 little or no as it begins
pain. They
appear to
activate
Implement use
psychodynami
of Range of To reduce
c mechanisms
Motion drug therapy
that impair the
Exercises, and as possible;
registering of
relaxation however,
pain (“gate
these may
closing”)
add to the
theory and
action of
nociceptive
pharmacolog
transmission).
ic regimen
Reference:
DEPENDENT
Brunner &
Suddarth.
Textbook of
Medical – Administer
Surgical analgesics To have
Nursing. Ed 12. IVTT as quick time for
Vol. 1 prescribed onset of
relieving
pain, patient
is for NPO
136
DESIRED EVALUATION
DIAGNOSIS NEED INTERVENTIONS RATIONALE INTERVENTIONS RATIONALE
OUTCOME STATEMENT
Fatigue r/t post- Within 8 hours of INDEPENDENT Goal Met.
operative P Nursing
Retain Nursing
Interventions
To continue
progress of
experience as
manifested by
H Interventions, Establish To gain Was able to improving
rapport to the client’s trust demonstrate patients level
evidence of Y patient and improved of energy
weakness and cooperation
deep sleep S >Demonstrate
level of
energy by
Cues:
I improved level of Monitor vital To see
having rest
energy signs trends
O specifically to frequently and including periods
Objective: interpret it
L participate in
accurately
progress of
condition or Appeared
therapeutic
>After operation,
patient is on bed
O activities at level
any unusual relax and
signs calm
rest G of ability
>Flat on bed and I Cooperates
shows evidence of during
weakness C >Restore energy
Provide with
rest intervals
To prevent
administratio
fatigue
through rest with quiet n of
>Steady and in intervals environment medication
deep sleep for 4 and well-
hours
N ventilated area
>Vital Signs: E Provide
comfort To enhance
T=360 C E measures self-image
PR=70 bpm
RR=18 cpm D such as
massaging of
BP=120/70 hands or back
mmHg and by staying
with the
patient
137
Implement use
of Range of To promote
Background Motion level of
Knowledge: Exercises, and energy by
relaxation conducting
Fatigue is exercise and
common promoting
after major circulation
surgery Provide patient
and delays with To let the
recovery. It opportunities patient feel
is usually for expressing you are
attributed feelings of concerned
to the irritation, and she’s not
physiologic weakness, or alone
al response discomfort
to surgery.
Fatigue is a Assist patient
common with setting To foster
health and achieving hope and
complaint. goals bring back
It is, her liveliness
however, Enhance
one of the patient’s For patient’s
hardest power fast recovery
terms to resources by and for her to
define, and fostering gain
a symptom patient confidence
of many involvement in and enhance
different decision strength
conditions. making by within self
Fatigue, enabling
also known patient to
as control
weariness, environment
tiredness, as appropriate
exhaustion
or lethargy,
is generally
Assess and
138
motivate
For the
patient’s
patient to
abilities to be
recover as
an active
defined as soon as
participant in
a feeling of possible
self-care
exhaustion
and
decreased
capacity for
physical
and mental
work DEPENDENT
Administer
medicines as
To provide
Reference: prescribed
comfort to
http://www.emedici client as well
nehealth.com/fatigu as alleviate
e/article_em.htm - fear and
December 23, 2010 anxiety
139
DESIRED EVALUATION
DIAGNOSIS NEED INTERVENTIONS RATIONALE INTERVENTIONS RATIONALE
OUTCOME STATEMENT
INDEPENDENT
Establish
rapport to the To gain
patient client’s trust
and
Altered comfort cooperation
secondary to pain Monitor vital
as manifested by signs To see
frequent sighing frequently and trends
and complaints of interpret it including
pain accurately progress of
condition or
Cues: any
unusualities
Objective:
Encourage
>Frequent sighing diversional To provide
activity like coping stress
>Complaints of listening to to alleviate
pain surrounding music the fatigue
the surgical site felt by the
client
>Can respond to Provide with
stimuli verbally and rest intervals To prevent
physically with with quiet fatigue
weakness noted environment
and well-
>Vital Signs: ventilated area
T=360 C Provide To bring
PR=70 bpm comfort Goal Met Continue back the
RR=18 cpm Within 8 hours of measures To enhance providing patient’s
BP=120/70 Nursing such as self-image The patient comfort energy loss
mmHg Interventions, massaging of was able to measures and and to
hands or back rest intervals restore
P >Enhance and by staying
have a deep
sleep for 4 proper body
with the
Background H comfort by
resting and patient
hours functions
Knowledge:
Y sleeping
Knowing S Implement use
that of Range of
someone I Motion To promote
you care Exercises, and level of
140
about has O relaxation energy by
just gone
through L conducting
exercise and
surgery
can make
O Provide patient
promoting
circulation
