Vii
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VII. NURSING CARE PLAN ASSESSMENT Subjective: The patient verbalized “Masakit ang sugat ko.” Pain Scale: 6/10 Objective: Vital signs: T= 36.5°C PR= 94bpm RR= 22 cpm BP= 130/90
facial grimace Speaks in slow paced manner. Guarding behavior
NURSING DIAGNOSIS Alteration in comfort related to acute pain
PLAN OF CARE
EXPECTED OUTCOME
EVALUATION
Independent: Short Term Goal: Goals met: After 30 mins -1 hour of Assess pain noting characteristics & After 30 mins. of severity ( 0-10 scale) Investigate& report nursing intervention: nursing interventions changes in pain as appropriate Patient will report pain is patient pain was at a tolerable level with a decreased from pain Assess vital signs noting tachycardia & pain scale of 3/10 scale of 6/10 to 3/10. increase in respiration Continue encouragement for efforts & use the patient will be able to After 30 mins of perform relaxation nursing intervention of relaxation techniques like deep exercises such as: the patient was able to breathing exercises perform the ff. • Proper positioning Assess degree of discomfort through relaxation exercises: verbal & non-verbal cues, note cultural • Deep breathing • Proper positioning influences on pain response exercises • Deep breathing Provide accurate, honest information to • Adequate rest periods patient exercises Keep at rest in semi-fowlers position • Adequate rest Long Term Goal: After 2 days of nursing periods Provide diversional activities like music intervention, the patient will have comfort and will be Dependent: relieved from pain as The patient was totally evidenced by pain scale of relieved from pain and Administer analgesics as indicated 0/10. had comfort Assist in oxygen inhalation as ordered
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facial grimace Speaks in slow paced manner. Guarding behavior
NURSING DIAGNOSIS Alteration in comfort related to acute pain
PLAN OF CARE
EXPECTED OUTCOME
EVALUATION
Independent: Short Term Goal: Goals met: After 30 mins -1 hour of Assess pain noting characteristics & After 30 mins. of severity ( 0-10 scale) Investigate& report nursing intervention: nursing interventions changes in pain as appropriate Patient will report pain is patient pain was at a tolerable level with a decreased from pain Assess vital signs noting tachycardia & pain scale of 3/10 scale of 6/10 to 3/10. increase in respiration Continue encouragement for efforts & use the patient will be able to After 30 mins of perform relaxation nursing intervention of relaxation techniques like deep exercises such as: the patient was able to breathing exercises perform the ff. • Proper positioning Assess degree of discomfort through relaxation exercises: verbal & non-verbal cues, note cultural • Deep breathing • Proper positioning influences on pain response exercises • Deep breathing Provide accurate, honest information to • Adequate rest periods patient exercises Keep at rest in semi-fowlers position • Adequate rest Long Term Goal: After 2 days of nursing periods Provide diversional activities like music intervention, the patient will have comfort and will be Dependent: relieved from pain as The patient was totally evidenced by pain scale of relieved from pain and Administer analgesics as indicated 0/10. had comfort Assist in oxygen inhalation as ordered
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