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NCP-Pain1

NCP-Pain1

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Published by java_biscocho1229
sample nursing care plan for nursing diagnosis of pain
sample nursing care plan for nursing diagnosis of pain

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Published by: java_biscocho1229 on Aug 02, 2010
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08/25/2014

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NURSING CARE PLAN: PAIN
Name of Patient:
Montalban Rizal
Age:
45 years old
Diagnosis:
Acute Pyelonephritis
CUESNURSINGDIAGNOSISANALYSIS/HEALTHIMPLICATIONGOAL ANDOBJECTIVESNURSINGINTERVENTIONSRATIONALEEVALUATIONINTERACTION
“Masakit ung dito(pertaining to thelower abdomen),tapos paggumagalaw akomasakit din.Minsan sa likod,tapos dito sa babang dibdib.”- When asked todescribe theintensity of pain ona scale of 1-10, thepatient said its 6
OBSERVATIONS
patient’s facialexpressions showsigns of pain- guardingbehavior on thelower abdomen- patient looksrestless and weakAcute pain relatedto acuteinflammation of renal tissues asmanifested bypatient’sverbalization,behavior, andchanges in vitalsigns
IMMEDIATE CAUSE
Acute inflammation of renal tissues
INTERMEDIATECAUSE
Acute pyelonephritis
ROOT CAUSE
Stone formation
HEALTHIMPLICATION
Genitourinary pain isusually caused bydistension of someportion of the urinarytract because of obstructed urine flowor inflammation andswelling of tissues.Severity of pain of pain is related to thesudden onset rather than the extent of distension.Unrelived acute paincan affect thepulmonary,cardiovascular,gastrointestinal,endocrine, andimmune systems. The
GOAL
After 8 hours of nursingintervention, theclient will be ableto reportrelief/control of pain.
OBJECTIVES
1) After 15-20minutes of physicalassessment, theclient will beassessed for precipitating/contributingfactors of hispain.1) Perform physicalassessment whichincludes locationand characteristicsof paina. Use painassessment scale toidentify intensity of pain.Pain is asubjectiveexperience andmust bedescribed by theclient in order toplan effectivetreatment.
Kozier,Fundamentals of Nursing, 7 
th
ed., p.1164
Provides baselinefor assessingchanges in painlevel andevaluatinginterventions.
Smeltzer & Bare,Medical Surgical 
1) Was the clientable to beassessed for precipitating/contributing factorsof his pain after 15-20 minutes of physicalassessment?Yes __ No __ If No, Why?
 
CUESNURSINGDIAGNOSISANALYSIS/HEALTHIMPLICATIONGOAL ANDOBJECTIVESNURSINGINTERVENTIONSRATIONALEEVALUATIONMEASUREMENT
Blood Pressure:150/90 up to160/90 mmHgRespiratory rate:25 up to 28breaths per minstress response(“neuroendocrineresponse to stress”)that occurs withtrauma also occurswith other causes of severe pain. Thewidespread endocrine,immunologic, andinflammatory changesthat occur with stresscan have significantnegative effects. Thisis particularly harmfulin patientscompromised by age,illness, or injury.
Smeltzer & Bare,Medical Surgical Nursing, 10 
th
ed., pp.218,1259
2) After 10-15minutes of interaction, theclient will be ableb. Assess andrecord pain and itscharacteristics:location, quality,frequency andduration.c. Note cultural anddevelopmentalinfluences affectingpain response.d. Monitor vitalsigns.Discuss with theclient the importanceof eliminatingprecipitating factors
Nursing, 10 
th
ed., pp.245 
Data assist inevaluating painand pain relief and identifyingmultiple sourcesand types of pain.
Smeltzer & Bare,Medical Surgical Nursing, 10 
th
ed., pp.245 
Each personexperiences andexpresses pain inan individualmanner using avariety of socialadaptationtechniques.
Kozier,Fundamentals of Nursing, 7 
th
ed., p.1164
Usually altered inacute pain.
Doenges,Moorhouse,Geissler-Murr,Nurse’s Pocket Guide, 9
th
ed., p.367 
Personal factorscan influencepain and paintolerance. Those2) Was the clientable to verbalizereduction of precipitating
 
CUESNURSINGDIAGNOSISANALYSIS/HEALTHIMPLICATIONGOAL ANDOBJECTIVESNURSINGINTERVENTIONSRATIONALEEVALUATION
to verbalizereduction of precipitatingfactors of pain.3) After 20-30minutes of intervention, theclient will beprovided withnon-pharmacologicmeasures toreduce pain.4) After 5 minutesof drugsuch as fear,fatigue, anxiety, andstress.a. Teach patient theuse of non-pharmacologictechniques such asrelaxation, musictherapy or distraction.b. Encourageadequate restperiods.Administer Diclofenacfactors that maybe precipitating or augmenting painshould bereduced or eliminated toenhance theoverall painmanagementprogram.
Fundamentals of Nursing, 7 
th
ed., p.1164
The use of non-invasive painrelief measurescan increase therelease of endorphins andenhance thetherapeuticeffects of painrelief medications.
Fundamentals of Nursing, 7 
th
ed., p.1164
To preventfatigue.
Doenges,Moorhouse,Geissler-Murr,Nurse’s Pocket Guide, 9
th
ed., p.367 
Analgesics aremore effective if factors of pain after 10-15 minutes of interaction?Yes __ No __ If No, Why?3) Was the clientable to be providedwith non-pharmacologicmeasures toreduce pain after 20-30 minutes of intervention?Yes __ No __ If No, Why?4) Was the client

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