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Nursing Care Plan Proper

Problem number 2: Acute pain


Subjective Data:
> “Masakit ang tiyan ko” as verbalized by the patient
> Characterized pain as “cramping” , localized in the epigastric area, aggravated by movement
> Rated pain as 5 from a scale of 1 to 10.

Objective Data:
> V/S: BP: mmHg, RR: 21cpm, PR: 65 bpm , Temperature: 36.6 ‘C
> conscious and coherent
> grimacing noted when moving
> guarding behavior noted
> slow careful movements noted
> needs maximum assistance in doing ADLs

Nursing Diagnosis:
Acute pain related to ongoing disease process

Explanation of the problem:

GOAL
Long Term Objectives: Within 2 days of nursing intervention, the patient will be able to:
- to perform ADLs with decreased non-verbal and verbal cues of pain as manifested by pain scale of 2/10, no grimacing and guarding behavior noted
Short Term Objectives: Within 8 hours of nursing interventions, patient will be able to verbalize relief of pain as manifested by:
- Pains scale of 5/10 from 3/10
- Less grimacing when moving
- Decreased incidence of needed assistance
- reports pain is within tolerable levels like experiences pain when pressure is applied to the affected area

Inteventions Rationale Criteria for Evaluation Evaluation


Diagnostic:
1. Assess PQRST of pain > Assists in differentiating the cause of >Long Term Objectives met if the
pain, provides information about patient able to:
development of complications and a. manage her ADL’s by
need/effectiveness of interventions. herself
LTO is partially met if one or two of
the objectives are met

LTO is not met if none of the


objectives are not met
2. Monitor vital signs especially > Vital signs serve as baseline data for
temperature and ability to do ADL evaluation of nursing interventions, an
increase in temperature is indicative >Short Term Objectives met if the
that a patient is having infection and to patient able to verbalize relief of
identify the work that the patient could pain as manifested by:
do. - Pains scale of 4/10 from
8/10
> To assess the need for and identify - Less grimacing when
3. Observe for non-verbal cues of pain
appropriate nursing intervention. moving
Observations may or may not be - Decreased incidence of
congruent with verbal reports
needed assistance
indicating need for further evaluation.
- reports pain is within
tolerable levels like
experiences pain when
pressure is applied to the
affected area
Therapeutic: > It will serve as non-pharmacologic
1. Promote bed rest pain management that could decrease STO is partially met if one or two
pain sensation by providing stimulus of the manifestations are met
conducive for wound healing.

STO is not met if none of the


manifestations are not met

> Proper positioning promotes better


2. Position patient on bed comfortably as to circulation on the area thus increasing
her preference that would most likely the blood supply therefore another
reduce the pain stimulus conducive for wound healing
that would later result to absence of
pain.

> Coldness can constrict the nerves in


3. Apply cold compress to the area as not the area therefore leading to decreased
contraindicated sensation on that specific region, thus
pain sensation is also decreased.

> Helpful in alleviating anxiety and


refocusing the attention of the patient
4. Make time to listen to and frequent
that would create distraction thus
interaction with the patient
decreasing pain.

> It improves circulation and hydration


for faster wound healing that would
5. Offer more fluids for consumption as not lessen the pain.
contraindicated

> It improves the oxygenation and


circulation to promote wound healing
6. Assist in doing DBE and eventually the absence of pain.
> It inhibits prostaglandin synthesis
by inhibiting Cyclooxygenase 1 and
7. Administer pan reliever as ordered 2 to produce anti-inflammatory,
analgesic, and antipyretic effects,
thus reducing the pain sensation.

> Provides information on patient’s


Educative: perception of pain for further
1. Encourage verbalization of feelings evaluation and to properly identify the
about pain treatment that could alleviate the pain.

> It prevents fatigue and aggravation


of pain that also helps in promoting
2. Instruct the patient to have adequate rest wound healing.

> In the case of absence of the nurse,


the SO can take charge in managing
3. Discuss with the patient and significant and helping to lessen the pain of the
others ways on lessening the pain and patient
preventing its aggravation