NURSING CARE PLAN
Patient’s name: Mrs. Mariz Delos Santos Chief Complaint: Pain Name of Student Nurse: Padilla, Noreen M.
Age & Gender: 32/F Admitting Diagnosis: Postoperative appendectomy
Birthdate: November 15, 1989 Date of Confinement: August 20, 2021
Address: Dagupan City
ASSESSMENT
NURSING
DIAGNOSIS
NURSING
ANALYSIS
PLANNING
INTERVENTION
RATIONALE
EVALUATION
SUBJECTIVE:
“Masakit pa din kung
saan siya inoperahan”
as verbalized by the
patient, with the pain
scale of 7/10.
OBJECTIVE:
-Facial grimacing
noted
-Guarding behavior in
the abdomen noted
-Distraction behavior
-Pale looking
Vital Signs:
Temp: 36.8°C
PR: 83 bpm
RR: 17 cpm
BP: 130/80 mmHg
Acute pain related to
presence of surgical
incision as evidenced by
facial grimacing and
slightly increased blood
pressure.
Pain is a subjective
incident usually
manifested by verbal
reports of the client.
It is important for
pain to be relieved to
promote client’s
health and well-
being
After 2 hours of nursing
intervention the patient
will be able to:
Report pain is
relieved and
controlled, with the
pain scale 3/10.
Appear relaxed, able
to sleep and rest
appropriately
Demonstrate use of
relaxation skills and
diversional activities,
as indicates for
individual situation
1. Establish rapport
2. Monitor the vital signs
3. Assess pain, noting
location, duration,
intensity (0-10 scale)
and characteristics
(dull, sharp, constant).
Investigate and report
changes in pain as
appropriate.
4. Provide accurate,
honest information to
patient and SO.
5. Keep at rest in semi-
fowler’s position.
6. Move patient slowly
and deliberately.
1. To gain trust and
cooperation with the
patient.
2. To obtain the baseline data
3. Useful monitoring
effectives of medication,
progression of healing.
Changes in characteristics
of pain may indicate
developing abscess or
peritonitis, requiring
prompt medical evaluation
and intervention.
4. Being informed about
progress of situation
provides emotional support,
helping to decrease anxiety.
5. To lessen the pain. Gravity
localizes inflammatory
exudate into lower
abdomen or pelvis,
relieving abdominal
tension, which is
accentuated by supine
position.
6. Reduces muscle tension or
guarding, which may help
minimize pain of
movement.
"I feel better", as
verbalized by the client.
The client was able to
report pain is relieved
or controlled with the
pain scale 3/10.
Client appeared relaxed
and able to sleep and
rest appropriately.
Client was able to
demonstrate use of
relaxation skills and
other methods to
promote comfort.
Vital Signs:
Temp: 36.5°C
PR: 90 bpm
RR: 19 cpm
BP: 120/80 mmHg
Level/Block/Group: 3BSN-03
Clinical Instructor: Sir Jesus C. Rabe
and Sir Dennis S. Baylon
