NCP

Patient’s Name: Mrs. M. G.
Medical Diagnosis: Complete Molar Pregnancy, 12 Weeks AOG

Nursing Diagnosis: Alteration in comfort: pain related to post surgical procedure
Short Term Goal: After rendering nursing care intervention, patient’s pain scale of 6/10 will decrease to 4/10
Long Term Goal: After hospitalization, the patient will be knowledgeable about different strategies that can be effective to relief
pain.
Cues Problem Scientific Nursing Intervention Rationale Evaluation
Reason
“Medyo Alteration Potential tissue o Re-assure patient that o Fear that pain will not be Goal partially
masakit padin in damage or you know pain is real and accepted as real, increases met.
ung tahi sa Comfort: described in will assist her in dealing tension and anxiety thus Patient’s pain
akin” as Pain terms of such with it. decrease pain tolerance. scale
verbalized by damage; decreased to
the patient. sudden or slow o Use pain of assessment o Provides baseline for assessing 5/10
onset of any scale to identify intensity changes in pain level and
Pain Scale: intensity from of pain. evaluating intervention.
6/10 mild to severe
with an o Assess and record pain o Data assist in evaluating pain
Objectives: anticipated and its characteristics: and pain relief and identifying
o with predictable end location, quality, multiply sources and types of
guarding and a duration frequency and duration pain.
behavior of less than 6
months. Independent:
o with facial o Re-position as indicated. o May relieve pain and enhance
grimace circulation.
o Provide quiet and calm o Quiet environment makes the
o weak in and quiet activities. patient feel relaxed and
appearance secured, thus decreased
anxiety.
o Respond immediately to o In the midst of painful

complaint of pain. experiences a patient’s
perception of time may
become distorted. Prompt
responses to complaints may
result in decreased anxiety in
the patient.
o Teach patient additional o Use of these strategies can be
strategies to relieve pain an effective pain relief.
and discomfort:
distraction.
o Provide additional o Improves circulation, reduces
comfort measures like muscle tension and anxiety
back rub. associated to pain.
o Encourage adequate rest o Prevents fatigue and
periods. conserves energy for healing.
Dependent:
o Administer balanced o Analgesics are more effective
analgesics as prescribed if administered early in pain
to promote optimal pain cycle. Simultaneous use of
relief. analgesics that work on
portions of the nociceptive
system will provide greater
pain relief with fewer side
effects.
Brunner & Suddarths’s Textbook
of Medical – Surgical Nursing 11th
Edition Volume 1
Patient’s Name: Mrs. M. G.
Medical Diagnosis: Complete Molar Pregnancy, 12 Weeks AOG
Nursing Diagnosis: Mild Anxiety r/t Situational Crisis
Short Term Goal: After rendering nursing care intervention, patient will verbalized that anxiety is reduced to a manageable level.
Long Term Goal: After hospitalization, the patient will be from anxiety.
Cues Problem Scientific Nursing Intervention Rationale Evaluation
Reason
“Naiinip na ako Anxiety Vague, uneasy Independent: Goal met. The
dito, ang tagal feeling of o Establish therapeutic o To elicit the trust and comfort patient
ko ng, tapos discomfort or relationship, conveying of the patient appears
palipat lipat pa dread empathy and relaxed and
ko ng kwarto.” accompanied unconditional positive reported
as verbalized by an regard. anxiety is
by the patient. autonomic reduced.
response (the o Maintain confident o Patient and SO can be affected
Objectives: source often manner (without false by the anxiety/uneasiness
o Poor eye non-specific or reassurance). displayed by health team
contact unknown to the members. Honest
individual); a explanations can alleviate
o with facial feeling of anxiety.
grimace apprehension
caused by o Answer all questions o Accurate information about
o weak in anticipation of factually. Provide the situation reduces fear and
appearance danger. It is an consistent information. assists patient and SO to deal
altering signal realistically with situation.
that warns of
impending o Encourage patient and o Sharing information elicits
danger and SO to communicate with support and comfort and can
enables the one another, sharing relieve tension of unexpressed
individual to questions and concerns. worries.
take measures
to deal o Provide rest o Conserves energy and
periods/uninterrupted enhances coping abilities.
sleep time, quiet
surroundings.

NCP

Uploaded by

Copyright:

Available Formats

NCP

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

NCP

Uploaded by

Copyright:

Available Formats

Patient’s Name: Mrs. M. G.

Medical Diagnosis: Complete Molar Pregnancy, 12 Weeks AOG

o Respond immediately to o In the midst of painful

You might also like