NURSING CARE PLAN
ASSESSMENT NURSINGDIAGNOSISSCIENTIFICRATIONALEPLANNING INTERVENTIONSRATIONALE EVALUATION
-unilateral back pain-pain frommovement of neck.
- compressing pain.
- radiating to butt
- pain aggravatedwhen coughing,sneezing, bendingand doing vulsulvamaneuver -pain suddenlysubsides for fewdays.-pain when raisingleg.
-limited ability to bend forward-tenderness inaffected area upon palpation.- (+) lasegue’s sign.-muscle atrophy of affected area.-Acute painrelated totrauma tointervertebraldisk.-the bones of thespinal column or vertebrae, run downthe back connectingthe skull to the pelvis.These bones protectnerves as they exit the brain and travel downthe back and then tothe entire body.HNP usually occurs ina posterior or posterolateral fashion,compressing thespinal cord and or nerve roots causing pain and neurologicsymptoms.
-after 8 hours of nursing intervention, patient will be ableto report relieved or controlled pain.
-after 2 weeks of nursing intervention patient will be ableto demonstrateuse of relationtechniques or skillsand diversionalactivities asindicated for individuals situation.-perform acomprehensiveassessment of paineach time painoccurs.-note patients locusof control.-observe for nonverbal cues.-monitor vital signs.-provide comfortmeasures.-encourage use of relaxation exercise.-encouragediversionalactivities.-administer analgesics asindicated to maximaldosage as needed.- encourage adequaterestperiods.-to rule out worseningof underlyingcondition or development of complications.-individual withexternal locus of control may take littleor no responsibility for pain management.-observations may or may not be congruentwith verbal reportsindicating need for further evaluation.-vital signs usuallyaltered in acute pain.-to provide non pharmacologic painmanagement.-to divert attention of the patient to theactivity rather than the pain.-to maintain acceptablelevel of pain.-to prevent fatigue.-patient may havedifferent levels of pain every time painis assessed.-patient may showlocus of controlaggravating pain if itsidentifiable by the patient.-patient may showgrimacing, guarding behavior.-patient may elicitincrease in vital signs.-provided comfortmeasures such as back rub, change of position.-patient used relationtechnique such asfocused deep breathing.-patient achievedminimal tolerablelevel of pain.-patient was able tohave adequate rest.