NURSING CARE PLAN

ASSESSMENT
DATA
DIAGNOSIS RATIONALE PLANNING INTERVENTIONS RATIONALE EVALUATION
SUBJECTIVE Acute Pain related After 6 hours of Independent After 6 hours of
Pain after a large open
CUE: to the effect of nursing 1.Assess reports of abdominal 1. Helps evaluate degree of nursing
 “Masakit na liwat it gastric acid secretion ileostomy operation can be interventions, the cramping or pain, noting discomfort and interventions, the
akon tiyan, didi on damaged tissue patient will be able location, duration, and effectiveness of analgesia patient was able to:
and skin and tissue significant. If the ileostomy to: intensity (using a 0 to 10 or or may reveal developing
dapit may akon
ileostomy” as irritation caused by is performed similar coded scale). complications a. Report pain is
verbalized ileostomies as a. Report pain is Investigate and report changes relieved or
 Verbalizes pain and evidenced by reports laparoscopically, pain is relieved or controlled in pain characteristics. controlled
discomfort, of pain, guarding typically just around the site
requesting behaviour, facial b. Appear relaxed 2. Note nonverbal cues, such as 2. Body language or b. Appear relaxed
analgesics at onset grimace, sleep of incisions. However, you restlessness, reluctance to nonverbal cues may be
of pain disturbance, may have more general c. Sleep and rest move, abdominal guarding, both physiological and c. Sleep and rest
restlessness, comfortably withdrawal, and depression. psychological and may be comfortably
OBJECTIVE irritability, sighing, abdominal pain or even Investigate discrepancies used in conjunction with
CUES: and distraction shoulder pain due to the air d. Verbalize between verbal and verbal cues to determine d. Verbalize
 Rated PRS as 7/10 behaviours nonpharmacologic nonverbal cues. extent and severity of the nonpharmacologic
with 10 being the used to inflate the abdomen methods that provide problem methods that
highest and 1 being relief provide relief
during the surgery. Pain
the lowest 3. Review factors that 3. May pinpoint
 Presence of from inflation will go away e. Demonstrate use aggravate or alleviate pain. precipitating or e. Demonstrate use
ileostomies at right of relaxation skills aggravating factors (e.g., of relaxation skills
in 24 to 48 hours. and diversional stressful events, food and diversional
lower quadrant and
left lower quadrant activities, as intolerance) or identify activities, as
of abdomen indicated, for developing complications indicated, for
(Source: individual situation individual situation
 Guarding
behaviour; www.augusta.edu/mcg/surgery/ 4. Encourage to verbalize 4. Reduction of anxiety or
protective gestures concerns. Active-listen these fear can promote
midds/patient_education/colost concerns, and provide relaxation or comfort
 Facial grimace
support by acceptance,
 Sleep disturbance omy_surgery.php)
remaining with patient, and
 Expressive behavior
giving appropriate
(restlessness,
information.
irritability, sighing)
 Distraction 5. Provide comfort measures 5. Promotes relaxation,
behaviour (pacing (e.g., mouth care, back rub, refocuses attention, and
and seeking out reposition). Assure patient enhance coping abilities
other people and that position change will not
activities) injure stoma.
NURSING CARE PLAN
6. Encourage use of relaxation 6. Helps patient rest more
techniques (guided imagery effectively and refocuses
and visualization) and attention, thereby
diversional activities. reducing pain and
discomfort

7. Observe and record 7. May indicate developing

abdominal distention, intestinal obstruction
increased temperature, and from inflammation,
decreased BP. edema, and scarring

8. Assist with ROM exercises 8. Reduces muscle/joint

and encourage early stiffness. Ambulation
ambulation. Avoid returns organs to normal
prolonged sitting position. position and promotes
return of usual level of
functioning
Collaborative
1. Administer medications as
indicated, such as:
a. Paracetamol 600mg IVTT a.Thought to produce
every 6 hours x 7 doses analgesia by inhibiting
prostaglandin ans other
substances that sensitize
pain receptors. Drug may
relieve fever through
central action in the
hypothalamic heat-
regulating center

b. Tramadol HCC 50g slow b. Thought to bind to

IVTT every 8 hours for opioid receptors and inhibit
severe pain reuptake of norepinephrine
and serotonin