Student Nursing Care Plane

Client : Ny. S
Care plan by : Ns. Nur Laily Oktavia
Date initiated : 04 November 2019

Assessment Diagnosis Outcomes Interventions Rationale Evaluation

Subjective data : Acute pain After 2 X 24 Observation : Observation : Subjective :

The patient said associated with hours of 1. Identify the 1. To find out The patient said
chest pain radiating physiological intervention it is location, the location, chest pain radiating
to the left arm, injury agents expected that characteristic, characteristic, to the left arm,
back and neck, characterized pain can be duration, duration, back and neck was
always by chest pain reduced by the frequency, quality, frequency, reduced, and
experiencing radiating to the following intensity of pain quality, condition began to
fatigue left arm, back criteria : 2. Pain scale intensity of improve
and neck which 1. Pain identification pain
Objective data : is aggravated complaints from 3. Identify factors 2. To find out Objective :
Consciousness by activity with scale 1 that aggravate and the scale of Consciousness
composmentis, pain such as (increased) to ease pain pain composmentis,
face grimaced,skin being hit by a scale 5 4. Monitor for side 3. To find out face grimaced,skin
turgor less than 2 heavy object on (decreased) effects analgesic the factors turgor less than 2
seconds, Gasgow a 9 to 10 scale 2. Grimance that aggravate seconds, Gasgow
Coma Scale 4-5-6 with a period of from scale 2 Therapeutic : and ease pain Coma Scale 4-5-6
10 to 15 (simply 1. Give non- 4. To find out
Vital sign : minutes, always increases) to pharmacological for side Vital sign :
Blood pressure : experiencing scale 5 techniques to effects BP : 120/80
90/80 MmHg fatigue, BP : (decreases) reduce pain analgesic MmHg
Temperature : 90/80 MmHg, 3. The 2. Facilitating rest T : 36.50C
370C T : 370C, breathing pattern and sleep P : 80X/menit
Pulse : 87X/menit from scale 2 (is RR : 19X/menit
Respiration : P : 87X/menit , quite bad) to Education : Therapeutic : P : activity
24X/menit RR : 24X/menit scale 5 1. Explain the causes, 1. In order to Q: like being hit by
(improving) periods, and reduce and a heavy object
P : activity triggers of pain ease pain R: chest radiating
Q : like being hit 2. Explain strategies 2. So that the to the left arm,
by a heavy to relieve pain patient feels back and neck
object comfortable S: 3
R : chest radiating Collaboration : and sleep T: less than 10 to
to the left arm, 1. Analgesic quality is 15 minute
back and neck collaboration sufficient
S : 9 to 10 Assessment :
T : 10 to 15 minute Education : The problem is
1. So that partially resolved
patients know
what causes, Plan :
triggers, and Intervention
the period of continued
pain
2. So that the
patient can
relieve his
pain
independently

Collaboration :
1. In order to
relieve pain