This nursing care plan summarizes 4 patients. It includes their diagnoses, goals of care, plans to meet those goals, how the plans were implemented, and an evaluation of whether the goals were met. The diagnoses included acute pain after surgery, altered nutrition after surgery, self-care deficits after surgery, and risk of infection after surgery. The plans involved assessing patients, teaching them, administering medications, and providing hygienic care. Evaluations showed the goals were fully met in relieving pain within 4 hours and improving nutrition, hygiene, and infection risk.

1. Nursing care plan
S.N Identifying
characteristics
Diagnosis Goal Planning Implementation Rationale Evaluation
1 Subjective
data:
Patient said, “I
have pain at the
surgical site.”
Objective data:
Fatigue
Restlessness
Rapid
breathing
Acute pain
related to
surgical
procedure.
Pain
will be
relieved
within
4 hours
of
nursing
care.
Assess the
cause,
location and
intensity of
pain.
Encourage
verbal
rapport
during and
after nursing
intervention.
Teach client
diversional
activities.
Administer
analgesics as
prescribed.
Such as
Inj.pcm 1
gm.
The cause,
location and
intensity of pain
were assessed.
Verbal rapport
was encouraged
during and after
nursing
intervention
Client was taught
about diversional
activities like to
have
conversation
with visitors,
deep breathing
Analgesic was
administered as
prescribed such
as Inj. pcm 1 gm
To identify
the level of
pain.
Pain is highly
subjective and
to identify
effectiveness
of
intervention.
To divert
client’s
attention from
pain
It reduces pain
and
discomfort
hence
enhances rest.
The goal
was fully
met as the
patient
within 4
hours as
evidenced
by the
verbalizati
on of
patient.

2. S. N Defining
characteristics
Nursing
Diagnosi
s
Goal Planning Implementat
ion
Rationale Evaluation
2 Objective data:
-Seems
dehydrated
-patient is in
NPO for 6
hours
-Patient is in
liquid diet
Altered
nutrition
and
comfort
related to
operative
procedur
e
Patient
will have
improved
nutrition
status and
will gain
comfort
within
hospital
stay.
-Assess the
patient’s
nutritional
status and
comfort.
-Assess the
prescribed
diet pattern
of the
patient.
-Assess the
level of
pain.
-Assess the
status of
patient’s
appetite
-provide
health
- Patient’s
nutritional
status and
comfort was
assessed.
-Prescribed
diet pattern
was liquid
diet after 6
hours of
NPO
-Level of
pain was
moderate.
-Status of
patient’s
appetite was
good
-provided
health
teaching to
-To know
the
nutritional
level of the
patient.
-To provide
health
teaching on
diet.
-To provide
comfort.
-To make
diet plan for
the patient.
-Goal
was fully
met as the
patient had
improved
her
nutritional
status and
comfort.

3. teaching on
nutritious
diet.
have
blacktea
daal, jaulo,
juice.
-To enhance
nutritional
status of the
patient.

4. S. N Defining
characteristics
Nursing
Diagnosis
Goal Planning Implementati
on
Rationale Evaluation
3 Subjective
data:
Verbalization
of lack of self-
care abilities
Objective data:
-Untidy hair
-Dirty Nails
-needs
Self-care
deficit
(personal
hygiene)
related to
surgery
Patient
will have
improve-
ed
personal
hygiene
within the
duration
of
hospital
stay.
-Assess the
level of
knowledge.
-Patient
will be
encouraged
to clean the
nails
-Patient
will be
encouraged
for hair
grooming.
-Patient
will be
provided
knowledge
regarding
health
hygiene.
-patient was
illiterate
-Patient
cleaned the
nails
-Patient
combed her
hair wash.
-Patient was
provided
knowledge
about health
hygiene to
brush twice a
day, to wash
hair once a
week, to
maintain hair
grooming.
-To get
base line
data.
-To
maintain
personal
hygiene
-To
maintain
personal
hygiene
-To
improve
health
status.
Goal was
fully met as
Patient had
improved
personal
hygiene.

6. S. N Defining
characteristics
Nursing
Diagnosis
Goal Planning Implementatio
n
Rationale Evaluation
4 Risk for
infection
related to
lack of
personal
hygiene
and
reduced
body
immunity
after
surgery
-Patient
will be
free
from
risk of
infection
within
hospital
stays.
-Assess the
vital signs.
-Patient
along with
his
caregivers
will be
provided
knowledge
regarding
hand
hygiene.
-provide
knowledge
to change
surgery
wound
pads every
4 hourlies
-Vital signs
were assessed.
Temp: 97.8° F
Pulse: 78b/m
Resp: 20b/m
BP: 90/60 b/m
-Patient along
with his
caregivers
was provided
knowledge
regarding
hand hygiene.
-patient
changed
surgery
wound pads
every 4
hourlies
-To obtain
baseline
data.
-To
prevent
cross
infection.
-To clean
the wound.
-Goal was
fully met as
patient was
free from the
risk of
infection.

7. -Anti-
biotic will
be
provided.
-injxone,
injmetron was
provided.
-To kill
micro-
organisms.