Nursing Care Plan for post operative client. At least 1 Nursing Problem and 5 Nursing Interventions with Rationales. (ADPIRE for)

 

Nursing Diagnosis:

Pain related to abdominal incision as evidenced by facial grimacing, profused sweating, and abdominal guarding.

Assessment

Subjective data:

Patient rated pain as 8 on the scale of 1 to 10 (1 as the lowest and 10as the highest)

Patient verbalized, "It hurts even more when I sneeze."

Patient verbalized, "Was awakened by the pain on my incision. Slept for only an hour."

Objective data:

Vitals signs:

Temp: 36.8degC

Respiratory rate: 22cpm

Pulse: 115bpm

BP: 130/80mmHg

Abdominal guarding, Facial grimacing, profused sweating noted.

Abdominal incision on the right upper quadrant:

Wound edges: pink, dry, no discharges noted

Wound dressing: clean, dry, intact

No foul odor noted

Desired outcomes:

Within my care, my patient will:

• verbalized decreased level of pain (from 8 to 4)
• exhibit vital signs within normal range
• appear relaxed, less abdominal guarding, able to get enough sleep.

Nursing interventions with rationale:

• Note patient's age, weight, coexisting medical or psychological conditions, idiosyncratic sensitivity to analgesics, and intraoperative course.
• Rationale: Strategies to postoperative pain management is based on multiple variable factors.
• Evaluate pain regularly (every 2 hrs noting characteristics, location, and intensity (0-10 scale). 
• Rationale: Provides information about need for or effectiveness of interventions. Note: It may not always be possible to eliminate pain; however, analgesics should reduce pain to a tolerable level. 
• Assess vital signs, noting tachycardia, hypertension, and increased respiration, even if patient denies pain.
• Rationale: Changes in these vital signs often indicate acute painand discomfort. 
• Assess causes of possible discomfort other than operative procedure.
• Rationale: Discomfort can be caused or aggravated by presence of non-patent indwelling catheters, or parenteral lines.
• Provide additional comfort measures: backrub, heat or cold applications.
• Rationale: Improves circulation, reduces muscle tension and anxiety associated with pain. Enhances sense of well-being.
• Encourage use of relaxation techniques: music therapy, deep-breathing exercises, guided imagery.
• Rationale: Relieves muscle and emotional tension; enhances sense of control and may improve coping abilities.
• Administer pain reliever as order by physician.
• Rationale: Provides effective pain relief.

Evaluation:

At the end of my care, my patient:

• rated pain as 4 (0 as the lowest and 10 as the highest)
• exhibit vital signs within normal range
• Vitals signs:

Temp: 37.3degC

Respiratory rate: 19cpm

Pulse: 100bpm

BP: 120/80mmHg

• appeared relax, less abdominal guarding, had 8 hours of sleep