HAGAD,

ALEJANDRO M. IV NURSING CARE PLAN BSN-3A

FEU-NRMF

Patient: Dela Vega, Maria Room: 437-D

Assessment Nursing Scientific Plan of care Intervention Rationale Evaluation

Diagnosis Analysis

Subjective: Acute pain Acute pain After 3-6 hours of Independent INDEPDENT After 3-6 hours of nursing
-Patient complains related to starts from nursing intervention the 1. Perform a 1) Pain is a subjective experience interventions the client has:
of slight pain on tissue nociception, client will have: comprehensive and must be described by the
the abdomen ischemia as from different assessment of pain to client in order to plan effective § Satisfactory pain
manifested by noxious stimuli § Satisfactory pain include OPQRST and efficient treatment control at a level
Objective: changes in (chemical, control at a level 2. Reduce or eliminate 2) Personal factors can influence less than (3 to 4) on
-Facial Grimace level of mechanical, less than (3 to 4) factors that precipitate pain and pain tolerance (Refer to a rating scale of (0
(Wong Baker Face consciousness thermal). on a rating scale the patient’s pain Gate Theory). Factors that may to 10).
Scale of 5/10) of (0 to 10). experience (fear, be precipitating or augmenting § Patient displays
-Guarding of chest § Patient displays fatigue, lack of pain should be reduced or improved well-
(protective body improved well- knowledge) eliminated to enhance the overall being such as
positioning) @ being such as 3. Provide support by pain management program. baseline levels for
RUQ Abdomen baseline levels giving encouraging 3) Providing support by giving pulse, BP,
-Restlessness for pulse, BP, words encouraging words reduces the respirations, and
respirations, and 4. Inform the situation to patient’s anxiety, especially if relaxed muscle tone
relaxed muscle the patient to reduce the pain is severe. or body posture (no
tone or body anxiety 4) Informing the patient what is the guarding)
Measurements: posture (no 5. Teach the patient to overall situation allows them to § Patient displays
T: 36.6 guarding) control his breathing on acknowledged what is happening improvement in
P: 97 § Patient displays depth and rhythm and may reduce anxiety which in mood, coping
R: 19 improvement in 6. Evaluate the patient’s turn will reduce panic and pain.
BP: 130/90 mood, coping. willingness and ability 5) With pain, all vitals signs are
to participate increased. Controlling the
7. Allow the patient to patient’s breathing pattern will
practice spirituality help the patient stabilize HR,
concentrate on breathing, which
distracts them from pain.
HAGAD, ALEJANDRO M. IV NURSING CARE PLAN BSN-3A
FEU-NRMF
Patient: Dela Vega, Maria Room: 437-D
8. Inform the patient’s
emergency contact
9. Secure all external
supportive devices
(BVM)
10. Assess for level of
consciousness
Dependent
Pharmacological interventions
include:
Nonnarcotic, Narcotic,
NSAIDS based on type and
severity of pain. T/C
Nitroglycerines.
Collaborative
Refer to the ER.
6) The patient must feel
comfortable trying a different
approach to pain management.
7) Allowing the client to practice
their spirituality should allay
anxiety and pain.
8) Informing the client’s
emergency contact like family
will give them a peace of mind.
Thus may reducing overall pain.
9) Depending on the severity of the
pain, the patient could become
belligerent or restless.
Equipment like nasal cannula,
BVM, ECG leads, should be
properly connected and in place
for effective planning of
treatment.
10) LOC could change to a variety
of factors, one of which is pain.
Asking their name, location,
visual acuity could show signs of
level of consciousness.
HAGAD, ALEJANDRO M. IV NURSING CARE PLAN BSN-3A
FEU-NRMF

Patient: Dela Vega, Maria Room: 437-D

DEPEDENT
Ensure that the administration of the
analgesic is practicing the 10 rights of
drug administration;

NSAIDS, Narcotic, Nonnarcotic, all

have analgesic effect which lowers the
pain.

These are given to control the pain;

usually given earlier to prevent from
having the pain to become more severe
(severe pain is more difficult to control
and increases the client’s anxiety
fatigue).

COLLABORATIVE
ER Team should be involved to provide
the necessary interventions to the
underlying problem.