Nursing care plan for acute pain related to hysterectomy

Nursing care plan for acute pain related to hysterectomy

Introduction

A nursing care plan is a comprehensive, systematic and individualized plan of care. It involves assessment, diagnosis, outcome identification, planning and implementation of activities carried out by a nurse with the patient, family and other healthcare providers to attain a desired health outcome. The focus of this nursing care plan is acute pain related to hysterectomy.

Assessment

The most common form of abdominal hysterectomy is total abdominal hysterectomy in which the entire uterus (including cervix) is removed through an abdominal incision. Therefore, the assessment must include: patient’s history of surgery, physical examination results, patient’s vital signs and assessment of the surgical site. Obtaining a detailed medical history is essential for effective management of acute pain.

Nursing Diagnosis

Acute pain related to tissue trauma from the hysterectomy procedure as evidenced by reports of pain at a level of 8/10 using a pain scale.

Outcomes

  • The patient will demonstrate comfort behaviors within two hours post-op.
  • The patient will verbalize effectively managed pain.
  • Panel of actionable strategies will be developed in collaboration with patient.

Interventions

  • Address pain through pharmacological and non-pharmacological interventions.
  • Provide education about the importance of pain management.
  • Encourage rest, positioning and mobilization according to individualized plan.
  • Implement relaxation techniques and distraction interventions to minimize pain perception.
  • Monitor side effects of opioid medications.
  • Administer PRN medications as necessary.

Rationales

  • Pain validations allow the patient to express their experience.
  • Education allows patient to understand their role in managing pain.
  • Positioning encourages proper tissue healing and promotes ineffective use of analgesics.
  • Relaxation techniques are a means of managing pain through diversion of attention.
  • Regular monitoring can identify medication associated side effects.
  • PRN medications reduce pain before steady state is reached.

Evaluation

The patient’s pain was managed successfully by implementing the nursing interventions. The patient was able to demonstrate comfort behaviors within two hours post-op, verbalize effectively managed pain, and develop a panel of actionable strategies in collaboration with the nurse.

Conclusion

Assessment of acute pain related to hysterectomy requires detailed medical history, physical examination, vital sign monitoring, assessment of surgical site, and management of pain pharmacologically and non-pharmacologically. The patient’s comfort level post-op is an indication of successful management of acute pain.

FAQs

  1. What is a nursing care plan?
    A nursing care plan is a comprehensive, systematic and individualized system of care designed to address an individual’s physical, psychological and social needs in order to achieve a desired health outcome.
  2. What are some interventions for acute pain related to hysterectomy?
    Interventions for acute pain related to hysterectomy include addressing pain through pharmacological and non-pharmacological interventions, providing education about the importance of pain management, encouraging rest, positioning and mobilization, implementing relaxation techniques and distraction interventions, monitoring side effects of opioid medications, and administering PRN medications as necessary.
  3. What is an indication that the nursing interventions are successful?
    An indication that the nursing interventions are successful is the patient’s comfort level post-op.
  4. How often should the patient be monitored after a hysterectomy?
    The patient should be monitored regularly to ensure that any side effects of the opioid medications are identified.
  5. What is the goal of a nursing care plan?
    The goal of a nursing care plan is to address an individual’s physical, psychological and social needs in order to achieve a desired health outcome.

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