Name: Ybarra, Geraldine

Age: 70 years old Date Identified:December 14, 2020

Dx: Congestive Heart Failure Date Evaluated: December 14, 2020

NURSING CARE PLAN

Problem: Pain scale of 6
ASSESSMENT NURSING INFERENCE PLANNING SCIENTIFIC EVALUATION
DIAGNOSIS INTERVENTION RATIONALE

Subjective Data: Acute pain related Pain is a subjective Assess the client. To assess the Goal met
“I notice they were to swelling as sensation of After the shift the client’s perception
evidence by 4mm discomfort derived patient will be able of pain. The Patient
getting a bit bigger
pitting edema in from multiple to: Allow the client to Verbalization is now able
and they are achy the lower sensory nerve verbalize allows outlet for to:
too.” as verbalized extremities interactions expressions about emotions and
Verbalize relief of
by the patient generated by pain. may enhance
leg pain within Verbalize relief of
physical, chemical, coping
appropriate time leg pain within
biological or Perform a mechanisms
frame for appropriate time
psychological comprehensive Provoking
administered frame for
stimuli. assessment of Factors: “What
Objective Data: medications. administered
Reference : pain. Determine makes your pain
- Swollen Brunner & better or medications.
via assessment
lower Suddarth’s Display reduced the location, worse?”
extremities Textbook of tension, relaxed
characteristics, Quality Display reduced
Medical - Surgical manner, ease of
- 2+ Moderate onset, duration, (characteristic): tension, relaxed
Nursing Volume 1 movement.
pitting frequency, “Tell me what manner, ease of
10th Edition
quality, and it’s exactly like. movement.
edema
Reports ability to severity of pain. Is it a sharp
- Limited
get enough sleep pain, throbbing Reports ability to
movement
- Restlessnes pain, dull pain,
s and rest stabbing, etc.” get enough sleep
Region and rest
- Q- Dull pain
- R-Lower Patient will report (location):
extremities Pain scale less “Show me Pain scale of 4
- S-Pain scale
than 6 where your pain
is.”
of 6/10 1+ mild pitting
Pitting edema Severity: Ask edema
- T- feel pain your pain to rate
grading will
when she’s pain by using
decrease
standing different pain
- RR= 19 rating methods
brpm (e.g., Pain scale
- BP= 140/90 of 1-10, Wong-
Baker Faces
Scale).
Temporal
(onset, duration,
frequency):
“Does it occur all
the time or does
it come and go?”
This promotes
Arrange for periods health, well-being
of uninterrupted and increased
rest in between energy level,
activities which are
important to pain
relief.

Sleep deprivation
can increase
Arrange for periods perception of
of uninterrupted pain.
sleep.

Allow client to To determine the

verbalize factors factors that
that triggers or should be put into
intensifies pain consideration
before
implementing
nursing
procedures that
involves
movements or
exercises that
exacerbate pain.

Introduce and To help client

demonstrate to focus on non-
theclient non - pain-related
pharmacologic matters.
techniques to relax
and control pain
such as: guided
imagery distracting
proper breathing
exercises reading

Continue to To ensure
administer the adequate pain
prescribed relief.
medication as
ordered/indicated.