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Nursing Care Plan: Subjective: During 8 Hours Nursing Management: (5) After 8 Hours

The nursing care plan summarizes the care for a 65-year-old male patient who is experiencing acute pain two days after undergoing coronary artery bypass grafting (CABG) surgery. The plan includes an assessment noting the patient's pain level is 8/10, facial grimacing, and vital signs. The nursing diagnosis is acute pain related to the postoperative CABG. The goals are for the patient to have decreased pain, be able to rest and sleep comfortably, and have a pain level less than 3/10 within 8 hours. Interventions include administering ordered analgesics, repositioning the patient, monitoring vital signs and pain levels, and providing breathing exercises. The evaluation after 8 hours found the patient's pain level

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Rawan Khateeb
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1K views4 pages

Nursing Care Plan: Subjective: During 8 Hours Nursing Management: (5) After 8 Hours

The nursing care plan summarizes the care for a 65-year-old male patient who is experiencing acute pain two days after undergoing coronary artery bypass grafting (CABG) surgery. The plan includes an assessment noting the patient's pain level is 8/10, facial grimacing, and vital signs. The nursing diagnosis is acute pain related to the postoperative CABG. The goals are for the patient to have decreased pain, be able to rest and sleep comfortably, and have a pain level less than 3/10 within 8 hours. Interventions include administering ordered analgesics, repositioning the patient, monitoring vital signs and pain levels, and providing breathing exercises. The evaluation after 8 hours found the patient's pain level

Uploaded by

Rawan Khateeb
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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NURSING CARE PLAN

Assessment Nursing Planning Intervention Rationale Evaluation


Diagnosis

Subjective: Acute pain During 8 hours After 8 hours:


related to The patient will Nursing Management: (5)  pain must be monitored he state being
as the patient verbalized, postoperative be free from in order for effective relieved of pain
he feels a pain in his chest of (CABG) pain complaint. - Assess pain regularly. relief to be provided. 3/10 scale.
after 2 day from a coronary
artery bypass grafting Decrease Pain  pain may be managed he able to rest,
surgery (CABG). scale less 3 on - Administer analgesics as through opioid displays reduced
1-10 scale. analgesics in conjunction tension, and sleeps
ordered.
with nonsteroidal anti- comfortably.
Objective: Patient will able inflammatory agents.
- Pain scale:8/10 to rest and sleep Vital Signs:
- Facial grimacing comfortably. - Reposition the patient HR:96bpm
 repositioning can help
- Cold and clammy skin. regularly. BP:135/89mmHg
control pain.
O2 Sat:98%
Vital Signs: RR:24npm
 to promote tissue Temp:37.3C°
HR 121bpm - assess blood pressure perfusion and prevent
BP 176/100mmHg and heart rate with each disruption of the surgical
anastomoses, blood
O2 Sat 105% episodes of chest pain. pressure be maintained
RR 36bpm within ordered
parameters. Respirations
Temp 35.8C°
may be increased as a
result of pain and
associate anxiety.
- assess patient in
 to improve breathing and
breathing exercises. to increase activity level.

Medical Mgt (5):

Gabapentin 300mg Oral.


Paracetamol 10mg IV

Al Riyada College for Health Sciences


Jamjoom Center, Jeddah, KSA
Name of Student: Logain Saud braik Date Submitted: ______________ MR: _________

Name of Hospital: _______________________________ Area: ______________ Room#:_____________

Patient Data

Name of Patient: Ahmad Age: 65year old Gender: Male

Nationality: __________________________ Marital Status: ________________________

DOA (Date of Admission): ______________

Medical Diagnosis: a coronary artery bypass grafting surgery (CABG).

Reason for admission: Acute Pain

CASE STUDY CONFIRMATION BY THE CI: __________________________ SIGN/DATE: ________________

References

American College of Physicians. (2000). A preoperative program for patients awaiting coronary artery bypass graft (CABG) surgery. Annals
of Internal Medicine, 133(4), 253. Retrieved from http://annals.org/article.aspx?articleid=713798
Zaman, A. G., Archbold, A., Helft, G., Paul, E. A., Curzen, N. P., & Mills, P. J. (2000). Atrial fibrillation after coronary artery bypass surgery:
A model for preoperative risk stratification. Circulation, 101, 1403-1408. Retrieved from http://circ.ahajournals.org/content/101/12/1403.full

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