Acedo, Nanette A. NG3-01 Patient name: Sgt. Dadula, Ricardo Y.

Diagnosis: Hip Sprain, Post traumatic Arthritis, hip Joint R Low back pain syndrome 2° to Lumbar strain.

NURSING CARE PLAN
CUES
Subjective Objective *facial grimace *restlessness *skin pale and moist *BP: 100/70bpm Temp: 36.1°C RR: 18 bpm PR: 89 bpm * pain scale 5/10

NURSING DIAGNOSIS
Acute pain related to disease process as manifested by facial grimace.

RATIONALE
A highly subjective state in which a variety of unpleasant sensations and wide range of distressing factors may be experienced by the sufferer. Pain may be acute, a symptom of injury or illness such as a myocardial infarction, or chronic, lasting longer than 6 months, the result of a long-term illness such as arthritis. Pain may also arise from emotional, psychological, cultural, or spiritual distress. Pain can be very difficult to explain, because it is unique to the individual; pain should be accepted as described by the sufferer.

GOAL
Short Term Goal: *At the end of the shift, patient will verbalize relief of pain from the scale of 5/10 to 2/10. *Follow prescribed pharmacological regimen. *Demonstrate use of relaxation skills and diversional activities, as indicated, for individual situation.

NURSING INTERVENTION
INDEPENDENT: *Established rapport through nurse patient interaction by respond immediately to compliant of pain

RATIONALE OF THE NURSING INTERVENTION *In the midst of painful experiences, patient’s perception of time may become distorted. Prompt responses to complaints may result may result in decrease anxiety in patient. Demonstrated concern for patient’s welfare and comfort fosters the development of a trusting relationship. *To distract attention and reduce tension.

EVALUATION
After 8 hours of nursing intervention, patient will: *Verbalized relief of pain from the scale of 5/10 to 2/10 *Acknowledged the importance of following prescribed pharmacological regimen *demonstrated use of relaxation technique and other diversional activities for pain.

“napapansin
kong may kirot sa likod nang baywang ko sa tuwing matagal akong nakadungo sa baba”, as verbalized by the patient.

*Instructed in use of relaxation techniques such as focused deep breathing, imaging, CD’s /tapes. *Encouraged diversional activities such as watching T.V or listening to radio and socialization with others. *Anticipated need for analgesics or additional methods of pain relief.

*To distract attention and reduce tension.

*One can most effectively deal with pain by preventing it. Early intervention may

to maximum dosage. Notify physician if regimen is inadequate to meet pain control goal. *To maintain “acceptable” level of pain. *Provided comfort measures (e. as needed. quiet environment. repositioning. use of heat/ cold packs. *to promote nonpharmacological pain management. calm activities. . touch. DEPENDENT: *Administered analgesics. as indicated.g. nurse’s presence).decrease the total amount of analgesic required.

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