Nursing Care Plan

Assessment Diagnosis Planning Interventions Rationale Evaluation

• Subjective: Acute pain r/t After rendering all Assess pain Use of a After rendering
Client verbalized, injury on his left the nursing intensity using a consistent, valid appropriate
-“sobrang sakit rib cage intervention, the self-report tool promotes nursing
talaga sa client’s level of measurement tool communication interventions,
kaliwang tagiliran pain will be and evaluation of client’s level of
ko.as verbalized decreased. pain intervention pain is decreased
by the patient. effectiveness.
(Black, p.1860)

• Objective: Note Verbal or

- Warm to touch environmental behavioral cues
-(+) Grimace influences may have no
- pain scale 8 out affecting pain direct relationship
of 10 response to the degree of
-T: 36.ºC pain perceived.
-PR: 78 bpm (Nanda, p. 390)
-RR: 20 cpm
-BP: 100/80 Monitor vital signs Usually altered in
mmHg acute pain
(Nanda, p.390)

Teach patient on Deep breathing

relaxation dilates the airway,
technique like stimulate
deep breathing surfactant
exercises at least production and
every 1 to 2 expands the lung
hours. tissue
(Black, p. 1860)

Provide comfort More likely be

measures like the successful in
use of heat/cold alleviating pain
compress. (Nanda, p.390)

Encourage More likely be

adequate rest successful in
periods alleviating pain
(Nanda, p.390

Provide calm and To promote

quiet environment wellness
(Nanda, p. 390)

Administer pain To maintain

medication acceptable level
(analgesics, of pain use of
opioids) as opioids is a
indicated common method
of postoperative
pain control.
Opioids bind to
opiate receptors,
decreasing
sensations of pain
(Black, p.1860)
Observe for side Side effects are
effects of monitored
medications used (Black p. 1860)

Assist client to Increasing/

alter drug decreasing
regimen, based dosage, stepped
on individual program helps in
needs. self-management
of pain.
(Nanda, p.390)