NURSING CARE PLAN

CUES NURSING ANALYSIS GOALS AND NURSING RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES INTERVENTIONS
S> “Masakit Acute pain Unpleasant GOAL:
pa din yung related to sensory and After all
sa may lower physical emotional nursing
body ko.” injuring experience intervention,
agents arising from the client will
S> “Minsan (Dilatation actual or report that
wala akong and potential pain is
ganang Curettage) tissue damage relieved/
kumain. or described in controlled.
Kumikirot pa terms of such 1. After
kasi.” damage; OBJECTIVES: 10 minutes of
sudden or 1. After nursing
S> Pain scale slow onset of 10 minutes intervention,
of 7/10 any intensity of nursing the client
from mild to intervention, was able to:
severe with an the client
O> Elevated anticipated or will be able Independent: - report pain
vital signs predictable to: • Perform pain • To rule out as it
BP – 140/90 end and a assessment each time worsening of occurred.
PR – 103 duration of 6 - report pain pain occurs underlying
bpm months. when it condition/developm
RR – 32 cpm occurs. ent of complications
T – 38.1°C Source:
NANDA 11th -describe the
O> ed., pp. 498 • Accept patient’s • Pain is a subjective pain as it
Positioning to description or pain experience and occurred.
avoid pain -describe the cannot be felt by
pain as it others
O> Guarding occurs.
behavior • Observe for non-
verbal cues • Pain is a subjective
O> Facial experience and
Grimace cannot be felt by
others
O> Slightly • Monitor vital signs
irritable
• It is usually altered 2. After
• Provide quiet by acute pain 15 minutes of
environment nursing
2. After • Promotes relaxation intervention,
15 minutes • Provide comfort the client
of nursing measures like back was able to
intervention, rub and change of • To provide non- verbalize
the client position pharmacological methods that
will be able pain management provide
to verbalize relief.
methods
that provide
relief. 3. After
• Assist client to learn 15 minutes of
breathing techniques • To assist in muscle nursing
3. After and generalized intervention,
15 minutes • Encourage client to relaxation the client
of nursing watch TV, listen to was able to
intervention, the radio, or socialize • Prevents boredom demonstrate
the client with others and enhances use of
will be able coping abilities relaxation
to skills and
demonstrate diversional
use of activities
relaxation
skills and
diversional
activities. Dependent: 4. After
• Administer analgesics the shift, the
as needed. Notify the • Administer prescribed
4. After physician if regimen analgesics as pharmacologi
the shift, the is inadequate to meet needed. Notify the cal regimen
prescribed pain control goal physician if regimen to alleviate
pharmacolog is inadequate to pain were all
ical regimen meet pain control carried out.
to alleviate goal
pain must all
be carried
out.