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COLLEGE OF NURSING

Silliman University
Dumaguete City

NURSING CARE PLAN


CUES/EVIDENCES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective: Altered comfort: Pain Within our care, Independent: At the end of our
• Rated pain as related to disruption patient will report pain • Monitor vital • Changes in vital nursing care, patient
3 in scale of 0- of tissue secondary is relieved as evidence signs signs often is relieved from pain
10 wherein 0 to mandibular repair by: indicate acute as evidenced by:
is the absence 1. V/S within normal pain and (Goal partially met)
of pain and 10 range: T = 36.5- discomfort. 1. V/S within
is the most 370 C • Review • Presence of normal range:
painful P = 60-70bpm, itraoperative narcotics and T- 36.5C
• Claimed that strong, regular record for type of droperidol in P-72 bpm
sometimes R = 16-20cpm, anesthesia and system R-20cpm
disturbed by silent, effortless medications potentiates BP-
the slight pain BP = 90-140/60- previously narcotic 120/90mmHg
on his mouth 90 administered analgesia, 2. Rated pain as 3
• Complained of 2. Rate pain as 0 in whereas in scale of 0-10
slight a scale of 0-10 inhalation wherein 0 is the
discomfort wherein pain 0 is • Evaluate pain anesthetics absence of pain
and pain due the absence of every 2 hours have no and 10 is the
to presence of pain noting analgesia most painful
catheter 3. Able to move characteristics, effects 3. Unable to move
Objective: head location, and • Provides head
• V/S: 4. Verbalized intensity. information 4. Still complained
T- 36.5C comfort Emphasize about need for of discomfort
P-72 bpm 5. Dressing dry and patient’s interventions. 5. Dressing dry
R-20cpm intact responsibility for and intact
BP- reporting
120/90mmhg pain/relief of pain
• Unable to move completely
head due to • Note presence of
pain the mouth anxiety or fear, • Concern about
and relate with the unknown
• Underwent nature of and and inadequate
surgery preparation for preparation can
(mandibular procedure heighten
repair) patient’s
• Tramadol 50mg perception of
q 8hrs IVTT pain
given (Imogene King:
• Dressing dry System
and intact Framework and
• Assess causes of Theory of goal
possible attainment)
discomfort other
than operative • Discomfort can
procedure be
caused/aggrava
ted by presence
• Provide of nonpatent
information about indwelling
transitory nature catheter,
of discomfort, as parenteral lines
appropriate • Understanding
the cause of
discomfort
provides
• Reposition as emotional
indicated reassurance.
(Margaret
• Provide Newman: Model
additional of Health)
comfort • May relieve
measures like pain and
back rub, heat or enhance
cold application circulation
• Improves
circulation,
reduces muscle
tension and
• Encourage use of anxiety
relaxation associated with
techniques like pain
deep-breathing (Betty Neuman:
exercise, guided Health Care
imagery, Systems Model)
visualization • Relieves muscle
and emotional
tension;
Dependent: enhances sense
• Administer of control and
medication as mat improve
indicated coping abilities
(Tramadol 50mg q
8hrs IVTT)
• Decreased pain.
Binds to mu-
opioid
receptors.
Inhibits
reuptake of
serotonin and
norepinephrine
in the CNS.