Nursing Care Plan

Date: January 17, 2011

Patient: J.F.
Case: Status Post Explore Laparotomy, Right Salpingo Oophorectomy
ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTIONS
Subjective Data: >Acute Pain related to Short term: Diagnostic: Short term:
>“Nasakit la unay release of prostaglandins >After 4 hours of >Asked the patient to Self report of a patient Goal met. The patient’s
daytunay naopera as an inflammatory nursing interventions, rate pain on a scale of 0 experiencing pain serves pain scale decreased
kanyak”, claimed by the response secondary to the patient’s pain scale to 10 as the first choice to from 8/10 to 5/10.
patient as both of her surgical operation will decrease from 8/10 obtain assessment
hands guard her to 5/10 information. Long term:
abdomen. Goal met. The patient’s
Long term: >Taken, monitored and Temperature, blood pain diminished and
>Patient coded report of >After 1 day of nursing recorded vital signs pressure, respiration performed activities like
8/10 pain in a scale of 0- interventions, patient’s rate, and pulse rate alter side movements and leg
10 (0 – no pain or pain will gradually as an autonomic bending and even
discomfort, 10-worst diminish and perform response when someone transferred from bed to
pain that one can activities like side is in pain. chair and vice versa.
experience) movement and leg
bending
Objective Data: Therapeutic:
>Pale >Offered position These following
>Diaphoretic change. measures aim to assist
>Seeking out other patient in relaxation
people >Provided a wrinkle free through attending her
>Sighs bed. comfort needs and other
>Irritable activities.
> Vigilant >Provided care in an
>Facial mask of pain unhurried, supportive
>Guarding behavior manner.
>Reduce interaction
with the environment >Involved patient in
>Muscle cramps decisions regarding care
activities.

>Keep the patient Room temperature and

ventilated with fan and lighting are
lighting. environmental factors
that influence the
patient’s response to
discomfort.
>Provided patient with
diversions through A pain management
cellular phone, verbal using non-
communication and pharmacologic technique
visitors. which desires to help the
patient focus on
activities rather than on
pain.
>Verbalized “this will
help relieve your pain” A positive approach in
when administering order to optimize patient
analgesic. response to analgesics.

>Review To reduce concern of the

procedures/expectations unknown and associated
and tell client when muscle tension at the
treatment will hurt. same time incorporate
suggestions for coping.

This is a non-steroidal
>Administered anti-inflammatory drug
Ketorolac 30mg which is likely due to
intravenously every 8 inhibition of the enzyme
hours as per doctor’s cyclo-oxygenase. The
order. analgesic activity is due,
in part, to relief of
inflammation.

A pain management by
Educative: which you provide
>Informed the patient information regarding
regarding the specific the medication as
analgesic medication she established by NIC
is taking, frequency of (Nursing Intervention
administration and Classification).
specific precautions.
To foster early recovery
and decline the hospital
>Encouraged early stay of the patient.
ambulation as directed
 by the physician.

Nursing Care Plan

Date: January 19, 2011
Patient: J.F.
Case: Status Post Explore Laparotomy, Right Salpingo Oophorectomy

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS
Subjective Data: >Risk for fluid volume Short term: Diagnostic: Short term:
>“Makain-inumakon”, deficit >After 4 hours of >Assessed mucous To monitor hydration Goal met. After 4 hours
claimed by the patient as nursing interventions, membrane, adequacy of status. of nursing interventions,
she touched the region the patient will have an pulses and blood the patient will have an
of her throat. adequate intravenous pressure. adequate intravenous
fluid intake. fluid intake as
Objective Data: >Taken, monitored and Intake and output are manifested by a properly
>furrowed tongue Long term: recorded amount of relevant factors that infused intravenous
>dry mucous membrane >After 1 day of nursing intake and output. greatly affects fluid fluid: 750mL of D5LRS
>decreased urine output interventions, patient imbalance. was infused within the
(20mL in 1 hour) will exhibit good shift and packed red
>increased urine hydration as manifested Therapeutic: blood cells was
concentration through moist mucous >Provided a drinking These measures promote completely infused at 1 2
>weakness membranes and ability straw when offering oral intake. noon.
>NPO to perspire. fluids
>hooked at a packed of Long term:
red blood cells to be > Provided frequent oral To alleviate dryness of Goal met. After 1 day of
infused for 4hours due at hygiene. the mouth and thus, nursing interventions,
12 noon preventing tissue patient will exhibit good
>with D5LRS at breakage. hydration as manifested
30gtts/min through moist mucous
>Ensured that To prevent under membranes and ability
intravenous fluids are infusion or over to perspire.
infusing at its necessary infusion.
flow rate discerned by
the physician.

Educative:
> Informed the patient to
inform the nurse of Thirst must be
thirst. responded immediately
to prevent the
aggravation of risk for
deficient fluid.