Nursing Care Plan
Name: JM
Age: 44 y.o
Sex: Female
Date of Admission: Feb. 03, 2010
Chief Complaints: abdominal enlargement
Medical Diagnoses: Ovarian New Growth
Assessment
Actual/Abnormal Cues:
 Client stated, “gasakit
siya kun mag-ubo kag
magkadlaw ko”.
 Client stated, “kis-a indi
ko masyado katulog di”.
 Guarded behavior
 Pain Scale= 8
(10 as highest)
 BP=130/90mmHg
Risk/Related Factors:
 Coughing causes pain
at surgical site.
 Sudden body
movement causes pain
at the surgical site
Strengths/Wellness:
 Strong Family support
 Compliance to medicine
 Strong faith with God
Nursing Dx
Acute pain r/t tissue Predisposing Factor: Age
trauma s/t post
abdominal surgery AEB
reported pain with a scale
of 8, sleep disturbance &
guarded behavior on
affected area.
Definition: Hyperstimulated ovaries
Unpleasant Sensory and
emotional experience
arising from actual or
potential tissue damage
or describe in terms such
damage; sudden or slow
onset of any intensity
from mild to severe with
an anticipated or
predictable end and a
duration of less than 6
months.
Source:
Douges, M.E. et.al.,
(2002). Nurse’s pocket
guide: diagnosis,
interventions &
rationales. (8th Edition).
Philadelphia: F.A. Davis
Company.
prostaglandin/bradykinin
Student Nurse: Yeana S. Alon
Year and Section: BN3B
Rationale Desired Outcome Nursing Intervention Justification Evaluation
After 8 hours of nurse- After 8 rourse of nurse-
(44 y.o) client interaction, my client interaction, my
client will be able to: Independent: client:
Increased luteinizing 1. Verbalize minimized  Monitor v/s and check  Alterations from 1. Goal Met. Stated that,
hormone or controlled feeling of dressing of affected normal may be signs “Kun mag ubo kag
pain. surgical site. of infection. Moistened kun gatawa ko dira
dressings are man lng siya gasakit,
favorable site for pero gadula dula man
microorganisms. siya ah. Ok naman
 Assess for signs of  To aid in evaluating ko.”
Hormonal imbalance pain, location, and need for proper
intensity and use of pain intervention. 2. Goal Met.
scale (0-10) and Continued pain may Distinguished ways on
Formation of Ovarian evaluate characteristics indicate developing how to relieve pain.
New Growth of pain. complication. Client stated, “Gainom
 Inform client to avoid  Prevent from nalng ko tubi para indi
weight bearing until complications on the magkatol akon
TAHBSO lymphnode allowed. incision site. tutunlan kag indi na
evaluation ko mag-ubo.”
2. Verbalize methods
 Encourage diversional  Allow the muscle to
that provide relief. activities and use of relax and serve as 3. Goal Met. Verbalized
Tissue trauma her way of relaxation.
relaxation exercises diversion from pain.
such as focused Client stated, “Gailis
breathing. ilis lang ko sang
Disruption of cell  Encourage adequate  Promote healing by posisyon ko di sa
membrane rest and sleep. reducing basal katre kag gaginhawa
metabolic rate and man ko kis.a dalum
allowing oxygen &
Start of inflammatory nutrients to be utilized
process for tissue regeneration
3. Demonstrate use of
 Provide comfort  Provide non-
Release of relaxation skills &
measures such as back pharmacologic pain
diversional activities
rub & change of management.
as indicated for her
position.
situation.
 Acute pain on surgical  Assist client in  Reduce swelling &
site with pain scale of 8 performing deep prevent stiffnes.
breathing exercise and Decreased lung
dorsiflexing of foot and capacity & decreased
Sleep disturbance, arms cough efficiency are
guarded behavior on predisposing factors of
surgical site. respiratory infection.

Collaborative:
 Administration of  NSAID activity
analgesics (Mefenamic includes modulation of
Source: Acid) T-cell function,
Smeltzer, S.C. & Bare, inhibition of
B.G. (2004).Textbook of inflammatory cell
medical-surgical chemotaxis,
nursing(10th Edition, decreased release of
Volume 2). Philadelphia: superoxide radicals or
Lippincott Williams and increased scavenging
Wilkins. of these compounds at
inflammatory site.
 Administration of  Antibiotics are used to
antibiotics (Amoxicillin) treat & prevent
infections caused by
susceptible pathogens
in skin structure.

Source:
Douges, M.E. et.al.,
(2002). Nurse’s pocket
guide: diagnosis,
interventions &
rationales. (8th Edition).
Philadelphia: F.A. Davis
Company.