D.

Nursing Care Plan

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE DATA Chronic pain related to After 8 hours of nursing  Allow patient to  Systematic After 8 hours of nursing
“Laging masakit ang likod niya. Disease process interventions, the client will: maintain a diary of tracking of pain interventions, the client
Hindi na siya makatulog.” As (compression/destructi pain ratings, appears to be an was able to:
verbalized by patient’s daughter on of nerve tissue/body  demonstrate use of timing, important factor
organs, infiltration of different relaxation skills precipitating in improving  demonstrate use of
nerves or their vascular and diversional activities events, pain different relaxation
supply, obstruction or a as indicated for medications, management. skills and
nerve pathway, individual situation treatments, and diversional activities
inflammation)as what works best as indicated for
OBJECTIVE DATA
evidenced by facial  report pain at a level less to relieve pain. individual situation
mask; expressive than 5 to 6 on a 0 to 10
 Autonomic responses behavior (restlessness, rating scale.  Aid the patient in  The nurse can  report pain at a
(diaphoresis, changes in BP, moaning, crying, making decisions increase the level less than 3 to 4
respiration, pulse) irritability)  use pharmacological and about choosing a patient’s on a 0 to 10 rating
 Changes in appetite/eating,
non-pharmacological particular pain willingness to scale.
weight; sleep patterns; management adopt new
pain relief strategies.
altered ability to continue strategy. interventions to  use
desired activities; Fatigue
 verbalize acceptable promote pain pharmacological
 Changes in sleep pattern relief through
level of pain relief and and non-
 Depression guidance and pharmacological
ability to rest
 Distraction/guarding comfortably support. The pain relief
behavior protecting body part patient may strategies.
 Facial mask; expressive begin to feel
behavior (restlessness, confident  verbalize acceptable
moaning, crying, irritability) regarding the level of pain relief
effectiveness of and ability to rest
these comfortably
interventions.

 Explore the need  Analgesic

for medications combinations
from the three may enhance
classes of pain relief
D. Nursing Care Plan

analgesics: opioids
(narcotics), non-
opioids
(acetaminophen,
Cox-2 inhibitors,
and nonsteroidal
anti-inflammatory
drugs [NSAIDs]),
and adjuvant
medications.

 Maintain the  Cognitive-

patient’s use of behavioral
nonpharmacologic strategies can
al methods to restore patient’s
control pain, such sense of self-
as distraction, control, personal
imagery, efficacy, and
relaxation, active
massage, and heat participation in
and cold their own care.
application

 Examine relevant  Most patients

resources for with cancer or
management of chronic
pain on a long- nonmalignant
term basis (e.g., pain are treated
hospice, pain care for pain in
center). outpatient and
home care
settings.