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    NCP Post Op

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    NIKKI CARYL ZAFRA
    1. The patient was experiencing acute pain related to an abdominal incision and colostomy secondary to surgery. 2. The nursing care plan included establishing rapport, assessing the patient's pain level and description, providing comfort measures like back rubs and distraction, instructing rest and slow movement, and administering pain medications as prescribed. 3. The goal was for the patient to report relief of pain within 8 hours of nursing interventions and participate in activities, which was achieved after 8 hours of care including comfort measures, rest, pain medication, and monitoring of vital signs and pain level.

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    NCP Post Op

    Uploaded by

    NIKKI CARYL ZAFRA
    51 views4 pages
    1. The patient was experiencing acute pain related to an abdominal incision and colostomy secondary to surgery. 2. The nursing care plan included establishing rapport, assessing the patient's pain level and description, providing comfort measures like back rubs and distraction, instructing rest and slow movement, and administering pain medications as prescribed. 3. The goal was for the patient to report relief of pain within 8 hours of nursing interventions and participate in activities, which was achieved after 8 hours of care including comfort measures, rest, pain medication, and monitoring of vital signs and pain level.

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    1. The patient was experiencing acute pain related to an abdominal incision and colostomy secondary to surgery. 2. The nursing care plan included establishing rapport, assessing the patient's pain level and description, providing comfort measures like back rubs and distraction, instructing rest and slow movement, and administering pain medications as prescribed. 3. The goal was for the patient to report relief of pain within 8 hours of nursing interventions and participate in activities, which was achieved after 8 hours of care including comfort measures, rest, pain medication, and monitoring of vital signs and pain level.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    51 views4 pages

    NCP Post Op

    Uploaded by

    NIKKI CARYL ZAFRA
    1. The patient was experiencing acute pain related to an abdominal incision and colostomy secondary to surgery. 2. The nursing care plan included establishing rapport, assessing the patient's pain level and description, providing comfort measures like back rubs and distraction, instructing rest and slow movement, and administering pain medications as prescribed. 3. The goal was for the patient to report relief of pain within 8 hours of nursing interventions and participate in activities, which was achieved after 8 hours of care including comfort measures, rest, pain medication, and monitoring of vital signs and pain level.

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    © All Rights Reserved
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    of 4

    CUES NURSING PLANNING NURSING DIAGNOSIS RATIONALE EVALUATION

    DIAGNOSIS (INDEPENDENT
    DEPENDENT NURSING ACTIONS)
    Subjective: - Acute pain Within 8 hours of 1. Established rapport. 1. Good communication skills are After 8 hours of
    “sakit akong related to nursing indispensable to basic concepts of nursing
    akong opera abdominal interventions, the nursing care as communicating interventions,
    maam labina inig incision patient will be able to effectively can help reduce the the patient was
    mo katawa ko” secondary report pain is relieved risk of medical errors, ensure able to verbalize
    as verbalized by to or controlled, appear better patient outcomes, and “okay na man
    the patient colostomy relaxed and able to nurture patient satisfaction (Lang ako paminaw
    Objective: as evidence participate in E. V., 2012) karon”.
    -guarding by activities 2. Assessed patient’s description 2. Pain is usually provoked by
    behavior verbalization appropriately. of pain activity and relieved by rest; joint Goal met.
    -abdominal of pain 7/10 pain and aching may also be N.ZAFRA
    discomfort present when the patient is at FSUU/SN
    -Grimace face rest. Pain may manifest as an
    ache, progressing to sharp pain
    when the affected area is brought
    to full weight-bearing or a full
    range of motion (Martin, 2019)
    3. Assessed pain every v/s taking. 3. Evaluation of pain is a
    requirement of proper patient
    care and is as important and basic
    as the assessment and
    management of
    temperature, blood pressure,
    respiratory rate, and heart rate
    (Walis, et.al, 2008).
    4. Performed a comprehensive 4. Pain is a subjective experience
    assessment of pain. and very individualized to the
    Determined via assessment person experiencing it. Effective
    the location, characteristics, pain assessments are crucial for
    onset, duration, frequency, patient care. Not only does
    quality, and severity of pain. controlled pain improve the
    patient’s comfort, it also
    improves other areas of their
    health, including their
    psychological and physical
    function (Moyle, S., 2015).
    Provides baseline for comparison
    to aid in determining
    effectiveness of therapy,
    resolution or progression of
    problem.
    5. Provided comfort measures— 5. Reduces muscle tension,
    back rub— and diversional refocuses attention, promotes
    activities. Encouraged stress sense of control, and may
    management techniques, such enhance coping abilities in the
    as progressive relaxation, management of discomfort or
    guided imagery, visualization, pain, which can persist for an
    and meditation. extended period.

    6. Instructed the patient to have 6. To prevent fatigue that can


    adequate of rest between impair ability to manage or cope
    activities. with pain.

    7. Maintain semi-Fowler’s 7. Facilitates fluid or wound


    position as indicated. drainage by gravity, reducing
    diaphragmatic irritation and/or
    abdominal tension, and thereby
    reducing pain.
    8. Move patient slowly and 8. Reduces muscle tension and
    deliberately, splinting painful guarding, which may help
    area. minimize pain of movement.
    9. Instructed the patient to 9. Carbohydrates and protein helps
    increase protein and for tissue repair and energy of the
    carbohydrate intake. body.
    10. Administer the pain 10. In this way it helps to alleviate
    medications as per the pain that felt the patient.
    prescription by the physician.

    CUES NURSING PLANNING NURSING DIAGNOSIS RATIONALE EVALUATION


    DIAGNOSIS (INDEPENDENT
    DEPENDENT NURSING ACTIONS)
    S- Imbalance Within 8 hrs of nursing - Established rapport. - Good communication skills are After 8 hrs of
    O- Muscle nutrition; intervention the indispensable to basic concepts of nursing nursing
    weakness less than patient will be able to care as communicating effectively can intervention the
    -fatigue body verbalize and help reduce the risk of medical errors, patient was
    -Presence of requirement understand the ensure better patient outcomes, and able to verbalize
    stoma in the right related to causative factors and nurture patient satisfaction (Lang E. V., and understand
    lower quadrant of insufficient necessary 2012) the causative
    the abdomen intake of interventions to - Assessed pain every v/s taking. - For the baseline data. factors and
    food promote optimum necessary
    nutrition. - Determined precipitating factors. - Identification and management of interventions
    underlying cause is essential to recovery. to promote
    - Performed auscultation bowel - Hypermotility of intestinal tract is optimum
    sounds. common and is associated with vomiting nutrition.
    and diarrhea which may affect choice of Goal met.
    diet/route. N.ZAFRA
    FSUU/SN
    - Encouraged small frequent meals and - Fulfilling cravings for desired food may
    snacks of nutritionally dense and non- also improve intake.
    acidic foods as food that prescribed by
    the physician.
    - Instructed the patient to have - To prevent fatigue that can impair ability
    adequate of rest between activities. to manage or cope with pain.

    - Discussed the importance of - These provide the pt information on


    adequate nutrition especially fluids, how nutrition could elevate her chances
    protein, vit.C, vit.B, iron calories and of faster recovery.
    potassium rich foods.

    - Kept strict documentation of intake - It is necessary to make an accurate


    output and calorie count. nutritional assessment.

    - Instructed the pt to limit foods that - To diminish gastric irritants that may
    include nausea and vomiting, avoid cause client to be reluctant to eat.
    serving very hot and spicy foods

    - Arranged for patient to consult with - Nutritional supplements, such as Ensure


    the dietitian to plan appealing, high- or Sustacal, may be recommended for
    protein meals that provide sufficient recovery of the patient.
    fiber, calories, and vitamins.

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