Nursing Care Plan

Patient Kieff

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective cues: Acute pain related Short-term goal: Independent nursing 1.Pain tends to become Short-term goal:
"Sakit kaayong akong to accumulation of Within 1 hour of nursing interventions: constant, more intense, and diffuse After 1 hour of nursing
pus on" as stated by fluid in abdominal intervention the patient 1. Investigate pain reports, noting over the intervention the patient
the patient. cavity (tubo ovarian wil be able to report location, duration, intensity (0–10 entire abdomen as inflammatory was able to report paint is
abscess) pain is scale), and characteristics. process accelerates; pain may alleviate/controlled as
Objective cues: alleviate/controlled. 2. Move patient slowly and localize if an abscess develops. evidenced by pain scale of
-abdominal pain deliberately, splinting painful area. 2.Reduces muscle tension and 6/10.
-shortness of breath Long-term goal: 3.Observe for nonverbal indicators guarding, which may help Goal met.
-restlessness Within 8 hours of of pain: moaning, guarding, crying, minimize pain of movement.
-guarding behavior nursing intervention the facial grimace. 3.Some patients may deny the Long-term goal:
Pain scale- 9/10 patient wil be able to 4.Obtain vital signs. existence of pain. These Within 8 hours of nursing
demonstrate relaxation 5.Assess the client’s current use of behaviors can help with proper intervention the patient
skills, and other medications. evaluation of pain. was able to demonstrate
methods to promote Independent nursing 4. Vital signs are usually affected relaxation skills, and other
comfort. interventions: when pain is present. methods to promote
6. Use nonpharmacological pain 5.Aids in planning and in comfort as evidenced by
relief methods (relaxation exercises, obtaining medication history. using breathing exercises
breathing exercises, music therapy). 6. Works by increasing the everytime pain occurs.
7. Provide optimal pain relief by release of endorphins, boosting Goal met.
administering prescribed pain relief the therapeutic effects of pain
medication. relief medications.
8. Provide cutaneous stimulation or 7. Various types of pain require A.CROSROJAS,
physical intervention such as different analgesic approaches. FSUU/SN
immobilization. Some respond well to non-opioid
Collaborative nursing pain relievers while others demand
interventions: a combination of non- opioid and
9. Evaluate the effectiveness of pain low dose opioid.
medications and ask to decrease or 8. Restriction of movement of a
increase dose and frequency as painful body part is another
nonpharmacologic pain
necessary.
10. Ask also the significant others to
determine the patient’s appetite,
bowel elimination, and the ability to
rest and sleep.
management.
9. Medications should be adjusted
to achieve optimum pain relief
without causing severe adverse
effects.
10. Side effects should be
monitored and managed
accordingly.