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Assessment Diagnosis Planning Intervention Rationale Evaluation Short Term Goal

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Cayla Mae Carlos

The patient reported acute pain after a cesarean section, rating it an 8/10. The nurse's plan was to administer pain medication, provide a calm environment, instruct deep breathing, and encourage rest. The short term goal was to relieve the patient's pain within 1 hour. The long term goal was to teach the patient ways to manage pain within 24 hours. After 1 hour, the patient's pain was a 3/10 and after 24 hours she could demonstrate managing her pain.

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Assessment Diagnosis Planning Intervention Rationale Evaluation Short Term Goal

Uploaded by

Cayla Mae Carlos
28 views2 pages
The patient reported acute pain after a cesarean section, rating it an 8/10. The nurse's plan was to administer pain medication, provide a calm environment, instruct deep breathing, and encourage rest. The short term goal was to relieve the patient's pain within 1 hour. The long term goal was to teach the patient ways to manage pain within 24 hours. After 1 hour, the patient's pain was a 3/10 and after 24 hours she could demonstrate managing her pain.

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NCP #2

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The patient reported acute pain after a cesarean section, rating it an 8/10. The nurse's plan was to administer pain medication, provide a calm environment, instruct deep breathing, and encourage rest. The short term goal was to relieve the patient's pain within 1 hour. The long term goal was to teach the patient ways to manage pain within 24 hours. After 1 hour, the patient's pain was a 3/10 and after 24 hours she could demonstrate managing her pain.

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

Assessment Diagnosis Planning Intervention Rationale Evaluation Short Term Goal

Uploaded by

Cayla Mae Carlos
The patient reported acute pain after a cesarean section, rating it an 8/10. The nurse's plan was to administer pain medication, provide a calm environment, instruct deep breathing, and encourage rest. The short term goal was to relieve the patient's pain within 1 hour. The long term goal was to teach the patient ways to manage pain within 24 hours. After 1 hour, the patient's pain was a 3/10 and after 24 hours she could demonstrate managing her pain.

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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Acute pain related to Short Term Goal: Dependent:


“Masakit ang tahi ko” as tissue injury secondary After 1 hour of nursing  Administer Tramadol,  Pharmacologic After 1 hour of nursing
verbalized by the client. to surgical incision; intervention the client will as ordered. treatment to intervention the client
Caesarian Section reported pain is controlled
be able to report pain is relieved pain.
Pain Scale: 8/10 with pain scale of 3/10.
relieved. Independent:
 Provide calm quiet
OBJECTIVE:  To avoid stress in
environment
- Facial grimace patient that may
- Guarding behavior worsen pain.
Long Term Goal  Instruct deep After 24 hours of
- Restlessness
After 24 hours of nursing breathing exercises continuous nursing
Vital signs taken:  Non-pharamacologic
intervention the client will intervention the client was
T: 36.2 measures that
be able to demonstrate able to manage pain.
P: 83 provides relief of
R: 20 ways on how to manage pain.
BP: 150/90 pain.  Encourage
diversional activities
(e.g. listening to  Increases release of
music) endorphins and
enhance the
therapeutic effects of
pain management
program.
 Encourage adequate  Promotes a relaxed
rest periods. feeling to the
patient.

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