Nursing Care Plan 3

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Independent: Independent:
Subjective Data: Acute Pain After 1 hour of 1.Provide comfort After 1 hour of
1.To promote
related to proper nursing measures such as proper nursing
“Grabe! Sobrang nonpharmacological
Uterine interventions,  the gently massaging interventions,  the
sakit hindi ko pain management and
Contractions client will report the lower back of the client reported relief
maexplain yung aid in the relaxation of
relief or control of client of pain and the vital
sakit sa puson at the muscles
pain and the vital signs improved
likod ko” as the
signs will improve.
client verbalized. AEB
 BP: 140/90 2.Note and 2.To rule out
Objective Data:   BP: 146/90
 Pain Scale: investigate changes worsening of
 Pain Scale:
Vital Signs:  6/10 from previous underlying condition
6/10
 Relieved reports of pain. or development of
August 2, 2021  Relieved
abdominal pain complications. 
(4:05 AM) abdominal pain
 Relieved lower
 Relieved lower
 BP: 190/120 back pain 3.Instruct and
back pain
mmHg encourage patient to 3.To relive client’s
 Presence of use breathing anxiety and promote
Abdominal techniques and muscle relaxation
  provide positive
Pain
 Presence of affirmations.
Lower Back
Pain 4. Encourage 4.To prevent fatigue.  
adequate
Physical rest periods.
Examination:

Assessment of 5. Advice the 5. To promote comfort

pain using PQRST patient to and prevent
– 9/10 find a unnecessary pain.
 position
where she is
comfortable. 
6. The impression of
6.Distract the patient pain is reduced by
drawing the person's
attention away from
the source of
discomfort. Reading,
watching TV, and
playing video games,
are just a few
examples.

Dependent:
Dependent: 
1. To help the
1. Provide patient in easing
pharmacologic the pain.
pain
management as
ordered. 2. It is indicated
2. Tramadol for the
and symptomatic
Paracetamol treatment of
37.5mg/325 moderate to
for pain as
severe pain.
per doctor’s
order.