West Visayas State University

College of Nursing
La Paz, Iloilo City

NURSING CARE PLAN

Nursing
Clustered Cues Nursing Diagnosis Rationale Outcome Criteria Rationale Evaluation
Interventions
Acute pain related to Unpleasant sensory The client will Assess the client. To assess the client’s
inflammation and emotional verbalize pain relief perception of pain.
experience arising or an acceptable
from actual or reduction in pain by Allow the client to Verbalization allows
potential tissue verbalize expressions outlet for emotions
damage; sudden or about pain. and may enhance
slow onset of any coping mechanisms.
intensity from mild to
severe with an Allow the client to To facilitate accurate
anticipated or rate the intensity of assessment of the
predictable end and pain in a scale of 0- client’s level of pain.
a duration of less 10 with 0 as no pain
than 6 months. and 10 as severe.

Pain is a subjective Arrange for periods This promotes

sensation of of uninterrupted rest. health, well-being
discomfort derived and increased energy
from multiple level, which are
sensory nerve important to pain
interactions relief.
generated by
physical, chemical, Arrange for periods Sleep deprivation can
biological or of uninterrupted increase perception
psychological stimuli. sleep. of pain.

Nociceptors or pain Depending on the To alleviate pain.

receptors are free client’s description of
nerve endings in the pain, administer the
skin that respond prescribed pain
only to intense, medication.
potentially, noxious
stimuli. A number of Continue to To ensure adequate
algogenic or pain- administer the pain relief.
causing substances prescribed
that affect the medication as
sensitivity of ordered/indicated.
nociceptors are
released into the Explain to the client To help the client
extracellular tissue as the process of relax by letting the
a result of tissue inflammation as a patient understand
injury. normal protective her present condition
response of the body and to assure her
Injury is defined as a to repair injured to that the pain she is
disorder in steady- tissues. experiencing is a
state regulation. Cell normal response of
or tissues of the the body to repair
body may be injured injured tissues.
or killed by physical,
chemical or The client will Allow client to To determine the
infectious agents. demonstrate non- verbalize factors that factors that should
When this happens, pharmacologic triggers or intensifies be put into
an inflammatory techniques for pain pain consideration before
response naturally relief by implementing
occurs in the healthy nursing procedures
tissues adjacent to that involves
the site of injury. movements or
Inflammation is a exercises that
defensive reaction exacerbate pain.
intended to
neutralize, control or Help client to a To help client
eliminate the comfortable position. determine proper
offending agent and bed positions that
to prepare the site alleviate pain.
for repair. It is meant
to serve as a Introduce and To help client focus
protective function, demonstrate to the on non-pain-related
After the injurious client non- matters.
agent is removed, pharmacologic
the inflammation techniques to relax
subsides and healing and control pain such
takes place with the as:
return of normal or guided imagery
near-normal distracting
structure and proper breathing
function. exercises
reading
Reference:
Brunner & Suddarth’s Implement Non-pharmacologic
Textbook of Medical- alternative pain- techniques for pain
Surgical Nursing control techniques, relief will not be
Volume 1 10th Edition once client’s pain effective unless
level has subsided. patient’s perception
of pain is at a
tolerable level.