Lyceum of the Philippines University
College of Nursing
NURSING CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Acute Pain related to Short-Term Goal: Assess pain level Monitoring pain helps Short-Term:
“Sumasakit ‘yung tahi ko surgical incision as Within 8 hours, the regularly using a pain evaluate the effectiveness Patients reported
kung saan ako evidenced by verbal patient will report a scale. of interventions and adjust a reduction in pain
naoperahan.” reports of pain, facial reduction in pain level treatment as needed. level to 3/10 within 8
grimace, and pain from 6/10 to 3/10. hours.
Objective: scale rating of 6/10. Administer prescribed Pain relief medications
Long-Term Goal: analgesics as ordered. help manage discomfort Long-Term:
Facial grimace Within 1 week, the and promote healing. After 1 week, the
observed. patient will demonstrate patient verbalized
Pain scale: 6/10. effective pain Teach the patient to Supporting the site understanding of pain
Guarding behavior management techniques support the incision site minimizes strain and management
over the incision and participate in light with a pillow or hand reduces pain. techniques,
site. physical activities without when coughing or demonstrated proper
Limited movement discomfort. moving. wound care, and
due to pain. resumed light physical
Inspect the surgical site Early detection of infection activities without
PR: 72 bpm for signs of infection like prevents complications discomfort
RR: 20 cpm increased redness, and promotes timely
Temp: 36.6 swelling, or drainage. management.
O2sat: 97%
BP: 120/70 Encourage gradual Early ambulation promotes
mobilization and walking circulation, prevents
within the patient’s pain complications like blood
tolerance. clots and aids recovery.
Educate the patient Proper care reduces the
about proper wound risk of infection and
care and hygiene. promotes healing.
Lyceum of the Philippines University
College of Nursing