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    Subjective: Independent: Assessment Diagnosis Planning Intervention Rationale Evaluation

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    Fau Fau Dheobo
    The patient presented with acute pain from a recent surgical incision, reporting a pain scale of 8/10. Over 8 hours of nursing intervention including monitoring vitals, positioning the patient comfortably, providing a restful environment, encouraging rest and relaxation techniques, the patient's pain reduced to a scale of 5/10. The goal of identifying improvement or changes in pain was partially met. The patient also had impaired skin integrity from the surgical wound. Over 4 hours of nursing intervention including wound care, dressings, and health teaching, the client's skin integrity was intact with no signs of inflammation or drainage, meeting the goal.

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    Subjective: Independent: Assessment Diagnosis Planning Intervention Rationale Evaluation

    Uploaded by

    Fau Fau Dheobo
    73 views2 pages
    The patient presented with acute pain from a recent surgical incision, reporting a pain scale of 8/10. Over 8 hours of nursing intervention including monitoring vitals, positioning the patient comfortably, providing a restful environment, encouraging rest and relaxation techniques, the patient's pain reduced to a scale of 5/10. The goal of identifying improvement or changes in pain was partially met. The patient also had impaired skin integrity from the surgical wound. Over 4 hours of nursing intervention including wound care, dressings, and health teaching, the client's skin integrity was intact with no signs of inflammation or drainage, meeting the goal.

    Original Description:

    Nursing Care Plan

    Original Title

    NCP

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    The patient presented with acute pain from a recent surgical incision, reporting a pain scale of 8/10. Over 8 hours of nursing intervention including monitoring vitals, positioning the patient comfortably, providing a restful environment, encouraging rest and relaxation techniques, the patient's pain reduced to a scale of 5/10. The goal of identifying improvement or changes in pain was partially met. The patient also had impaired skin integrity from the surgical wound. Over 4 hours of nursing intervention including wound care, dressings, and health teaching, the client's skin integrity was intact with no signs of inflammation or drainage, meeting the goal.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    73 views2 pages

    Subjective: Independent: Assessment Diagnosis Planning Intervention Rationale Evaluation

    Uploaded by

    Fau Fau Dheobo
    The patient presented with acute pain from a recent surgical incision, reporting a pain scale of 8/10. Over 8 hours of nursing intervention including monitoring vitals, positioning the patient comfortably, providing a restful environment, encouraging rest and relaxation techniques, the patient's pain reduced to a scale of 5/10. The goal of identifying improvement or changes in pain was partially met. The patient also had impaired skin integrity from the surgical wound. Over 4 hours of nursing intervention including wound care, dressings, and health teaching, the client's skin integrity was intact with no signs of inflammation or drainage, meeting the goal.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

    Subjective: Acute Pain After 8 hours INDEPENDENT Goal Partially


    “Masakit po related to of nursing Assessed patient’s To identify Met:
    yung sugat surgical intervention, pain scale improvement After 8 hours of
    ko.” as incision as the patient’s or any nursing
    verbalized by manifested pain will be changes in intervention, the
    the patient by pain reduce. patients pain patient’s pain
    scale of 8 reduced with a
    Objective: over 10. Monitored vital signs To determine pain scale of 5
    Weakness every 2 hours any changes out of 10.
    Pain Scale of 8 or alteration
    over 10 in the
    patient’s vital
    Vital Signs: signs
    Temp: 36.8oc
    PR: 90 bpm Placed patient in a For the
    RR: 20 cpm comfortable position patient’s
    BP: 120/80 comfort
    mmHg
    Provided a well For the
    ventilated and restful patient’s
    environment comfort

    Encouraged adequate To prevent


    rest periods fatigue that
    can impair
    ability to
    manage and
    cope with
    pain

    Taught patient To help the


    relaxation technique patient
    such as Deep alleviate the
    Breathing Exercise pain

    To divert
    Offered diversional or patients
    distraction activities attention
    such as books, from pain
    television, or movies.
    To evaluate
    Encouraged coping
    verbalization of abilities and
    feelings about the to identify
    pain such as concern areas of
    about tolerating pain. additional
    concern

    DEPENDENT
    Administered To help
    prescribed analgesic reduce
    as ordered by the patients pain
    Physician
    ASSESSMENT DIAGNOSIS PLANNING INTERVENTIO RATIONALE EVALUATION
    N
    Subjective: Impaired Skin After 4 hours of INDEPENDENT Goal Met:
    “Masakit po Integrity nursing Assessed vital
    yung sugat ko.” related to intervention, signs every 2 After 4 hours of
    as verbalized surgical wound the client will hours nursing
    by the patient manifest intact intervention,
    skin integrity as Done proper the client
    Objective: evidence by aseptic wound manifested an
    Weakness absence of care using intact skin
    Pain Scale of 8 inflammation, appropriate integrity as
    over 10 redness, barrier evidenced by
    purulent dressings, no presence of
    Vital Signs: discharges on wound inflammation,
    Temp: 36.8oc skin or coverings or redness or
    PR: 90 bpm operative site. skin protective purulent
    RR: 20 cpm agent as discharges
    BP: 120/80 needed noted on the
    mmHg surgical site.
    Cleansed skin
    surface with
    water and mild
    soap after
    incision is
    sealed

    Checked
    tension of
    dressings and
    apply tape

    Given health
    teaching on
    proper wound
    care or dressing
    and importance
    of not touching
    the wound

    DEPENDENT
    Administered
    prescribed
    medications as
    ordered by the
    physician

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