ACUTE PAIN

A Nursing Care Plan Presented to the

Faculty of the Nursing Department
San Pedro College
Davao City
MR. MARC JADE ADLAWAN, RN

In Partial Fulfillment of
The Requirements in NCM 216-RLE
GASTROINTESTINAL / METABOLISM NURSING ROTATION

BY:
CLARISSA S. TORRES, ST.N.

April 12, 2021

Name of Patient: A.B.C Attending Physician: Dr, Grey Ward & Room No.:
Chief Complaint: Chest pain Diagnosis: Hiatal hernia
Date Cues Ne Nursing Patient Outcomes Interventions Imple Evaluation
& ed Diagnosis ment
Time ation
SUBJECTIVE: C Acute Pain Within 2 hours of - Create a quiet, non- 4 April 10, 2021
A Pain scale of O related to nursing care, patient disruptive environment with @ 10 AM
P 2 out of 3 G displacement will display relief from dim lights and comfortable
R 3-Severe pain N of stomach pain as evidenced temperature when possible. “GOAL MET”
I 2-Moderate I into the chest by: R: Comfort and a quiet
L pain T cavity atmosphere promote a After 2 hours of
1-Mild pain I secondary to a. vital signs relaxed feeling and permit the nursing care, patient
10, 0-no pain V hiatal hernia maintained within client to focus on the displayed relief from
“Sakit akong E as evidenced normal range; relaxation technique rather pain as evidenced
2 dughan ug - by pain scale Temp: 36.5-37.5°C than external distraction. by:
0 sa ubos sa P of 2 out of 3, PR: 60-100 bpm
2 dughan dapit E facial RR:13-21 cpm - Determine factors that 2 a. vital signs
1 labaw na inig R grimace, and CR: 60-100 bpm alleviate pain. maintained within
pahigda gani C guarding BP: 110/70-130/90 R: Information on these normal range;
@ ko, usahay E behavior mmHg alleviating activities can be Temp: 36.5°C
kay maski P integrated in planning for an PR: 87 bpm
8AM mulingkod T RATIONALE: b. absence of facial optimal pain management. RR:20 cpm
sakit sad”, as U Hiatal hernia grimace and CR: 89 bpm
verbalized A or also called guarding behavior; -Evaluate and document his 10 BP: 120/80 mmHg
by the L diaphragmati and response to relaxation
patient. c hernia is a therapy B. absence of facial
“Ang sakit P condition in c. report of R: Conveys to the health care grimace and
kay A which parts satisfactory pain team effective strategies in guarding behavior
mupadulong T of the control at level 0 on a reducing or eliminating pain.
rating scale of 0-3. C. reported
 sa akong left T abdominal 3- Severe pain -Monitor vital signs. 1 satisfactory pain
nga E organs 2-Moderate pain R: alterations may signify control at level 0 on
shoulder. R including the 1- Mild pain abnormalities associated with a rating scale of 0-3.
Bag o ra N stomach are 0-no pain pain. Moreover, it is done to
man ni siya displaced evaluate the effectiveness of 3-Severe pain
nagsugod, through an the treatment as increase in 2-Moderate pain
mga 3 days opening in values may indicate pain. 1-Mild pain
pa sad”, as the 0-no pain
verbalized diaphragm - Instruct client to report any 9
by the into the chest improvement/exacerbation in
patient. (thorax). With pain experience.
this, the R: Unrelieved pain can create
stomach other problems such as
OBJECTIVE: becomes anger,anxiety, immobility,
Irritability trapped respiratory problems, and
Exhibited above the delay in healing.
Facial diaphragm.
grimace This unusual - Encourage and assist client 3
upon lying protrusion or to do deep breathing
down displacement exercises.
Restlessnes of the R: Deep breathing for
s stomach relaxation is easy to learn and
Shortness of causes chest contributes to pain relief
breath pain which and/or reduction by reducing
Guarding can be muscle tension and anxiety
behavior manifested
noted through self - Administer medications, 5
Pale skin report of pain particularly analgesics, as
Moaning through a ordered.
when lying scale, facial R: Analgesics are
 down grimace and classification of medications
Profuse guarding that provides relief from pain.
sweating behavior.
Limited - Instruct the patient to avoid
range of Reference: carbonated beverages and 7
motion Eades,S. gas-producing food.
(ROM) (n.d.). R: to reduce abdominal
Vital Signs at Diaphragmati distension which can worsen
8:00 AM c hernia: acute pain
Temp: 36.4 C causes,
BP: 130/90 symptoms, - Instruct patient to avoid
HR: 95 bpm treatment. tight-fitting clothes. 8
PR: 93 bpm Retrieved R: clothes that are tight
RR: 25 cpm from: around the waist put extra
https://imedic pressure on the stomach and
alsociety.org/ esophageal sphincter
diaphragmati
c-hernia/ - Encourage patient to follow
appropriate meal times and 6
meal portions.
R: To ensure that the patient
does not eat a huge meal, or
that he/she does not eat late
at night or before bedtime as
both of these may cause
reflux of acids or chest pain.
References:
Herdman,H. & Kamitsuru,S. (2018).Risk for Infection. Nursing Diagnoses Definitions and Classification 2018-2020 Eleventh Edition.
Page 184
Hinkle,J. & Cheever,K. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 14 th Edition. Wolters Kluwer. Page 799

Wayne, G. (2020). Acute Pain Nursing Care Plan. https://nurseslabs.com/acute-pain/