NURSING CARE PLAN Problem: Acute Intermittent Moderate Pain

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ASSESSMENT

STATEMENT OF THE PROBLEM

PLANNING
Long Term Goal/Short Term Goal

NURSING ACTION
Nursing Interventions with Rationale Independent, Dependent, Interdependent

OUTCOME Goas was partially met as evidenced by: Subjective: “Nawawala na kaunti yung kirot ng ulo ko, kapag may kausap ako at nakakaidlip.” Pain Scale: 4/10 Objective: *Awake & afebrile *Smiling

Subjective/Objective Cues Subjective: “Kumikirot-kirot yung tinusukan sakin.” *Pain Scale: 6/10 *Quality: Throbbing *Frequency: Intermittent Objective: *(+) Facial grimace *With crutchfield tong *insertion *awake & afebrile

Nursing Diagnosis
Acute intermittent moderate pain r/t crutchfield tong insertion secondary to fracture dislocation Definition: Unpleasant sensory & emotional experience rising from actual or potential tissue damage. In this case, crutchfield tong insertion. Etiology: Due to potts disease, the client lost her balance and hyperextended her neck causing pain and fracture dislocation, because of this, the client undergone clutchfield tong insertion and with this, pain occurred. Background Theory: According to Virginia Henderson, It is one of the 14 needs of the client is to be free from pain and be safe at all times.

STG: At the end of eight (8) hours nursing intervention, client will be able to: *Verbalize a decrease in pain *Demonstrate use of relaxation techniques & other diversional activities.

Independent: *Provide bedside care. R: Bedside care helps in making the environment clean and pleasing to the eyes & feeling of the patient, thereby decreasing pain and promoting comfort. * Teach diversional activities such as chatting and listening to music. R: Diversional activities and relaxation techniques provides a refreshing feeling and effective way of diverting client’s attention to pain independently. *Instruct client to avoid moving as much as possible if unnecessary. R: Moving frequently that is unnecessary will cause pain to the patient. Dependent: *Administer pain reliver as prescribed. R: Prescribed pain relivers aids in alleviating the pain of the patient. Interdependent: *Assist in turning client q4 R: To provide comfort and prevent pressure ulcers that will cause pain.

LTG: At the end of two (2) months nursing intervention, client will be able to: *Be free from pain *Perform ADL independently without pain.