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 sensation of After the shift the client’s perception
discomfort derived patient will be able of pain. The Patient
getting a bit bigger
from multiple to: Allow the client to Verbalization is now able
and they are achy sensory nerve verbalize allows outlet for to:
too.” as verbalized interactions expressions about emotions and
Verbalize relief of
by the patient generated by pain. may enhance
legs pain within Verbalize relief of
physical, chemical, coping
appropriate time legs pain within
biological or mechanisms
frame for appropriate time
psychological Arrange for periods
administered frame for
stimuli. of uninterrupted This promotes
Objective Data: medications. administered
Reference : rest. health, well-being
- Swollen Brunner & and increased medications.
lower Suddarth’s Display reduced energy level,
extremities Textbook of tension, relaxed which are
Display reduced
Medical - Surgical manner, ease of important to pain
- Pain scale of tension, relaxed
Nursing Volume 1 movement. relief.
6/10 manner, ease of
10th Edition Arrange for periods
movement.
- Limited of uninterrupted Sleep deprivation
Reports ability to sleep. can increase
movement
get enough sleep perception of Reports ability to
- Restlessnes
s pain.
and rest Continue to get enough sleep
administer the To ensure and rest
prescribed adequate pain
Patient will report
medication as relief.
Pain scale less Pain scale of 4
ordered/indicated.
than 6

Allow client to
verbalize factors To determine the
that triggers or factors that
intensifies pain should be put into
consideration
before
implementing
nursing
procedures that
involves
movements or
exercises that
exacerbate pain.

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