Santiago, Arianne Belle S. Prof. Lyndon Rey Mendoza, R.N.

BSN3-2 22 February 2022

NURSING CARE PLAN

NURSING
ASSESSMENT ANALYSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
Subjective Data: Chronic pain The most Short Term Goal: Independent: Short Term Goal:
“I can barely stand, related to chronic common cause of After 1 hour of Aid the patient in making The nurse can increase GOAL MET – After
especially after musculoskeletal long-term hip pain undergoing the decisions about choosing a the patient’s willingness to 1 hour of undergoing
sitting for more than condition and is arthritis. nursing particular pain management adopt new interventions to the nursing
an hour. My hips age >50 years, Arthritis can interventions, the strategy. promote pain relief. interventions, the
and joints hurt a lot,” as evidenced by cause pain, stiff patient will be able patient was able to
as verbalized by the facial expression and tender joints, to reiterate Instruct use of cold/hot These diminish the pain reiterate techniques
patient. of pain, alteration and difficulty techniques or compress on affected areas. or behaviors that
in ability to walking. behaviors that enable resumption
Method: Interview continue enable resumption Dependent: of activities, as
previous Wayne, G. (2019). of activities, as Obtain prescriptions to Opioid doses should be discussed by the
Objective Data: activities and Chronic Pain: discussed by the increase or decrease adjusted individually to nurse.
BP: 130/80mmHg self-report of a Hips. Healthline. nurse. analgesic doses when achieve pain relief with
PR: 97 BPM score of 9 in the Retrieved from indicated. acceptable effects. Long Term Goal:
RR: 18 BPM Numeric Pain https://www.health Long Term Goal: GOAL MET –
Scale. line.com/health/hi After 2 weeks of Interdependent: After 2 weeks of
Pain Scale: 9 p-pain#causes undergoing the Instruct the family to assist These are measures to undergoing the
nursing patient when walking or doing prevent discomfort and nursing
-demonstrated interventions, the tedious activities, and to further injuries. interventions, the
decreased muscle patient will be able massage areas frequently. patient was able to
strength in to increase increase strength
extremities strength and Collaborative: and function of
function of Refer the patient to a physical These interventions affected body parts,
Method: IPPA affected body therapist for assessment and improve pain and report a rating
parts, and report a evaluation. management. of less than the
rating of less than previously reported
the previously Bueno, M. D. (n.d.). score in the Numeric
reported score in Effectiveness of nursing Pain Scale.
the Numeric Pain intervention for adult
Scale. patients experiencing
chronic pain. The Spanish
Centre for Evidence
Based Nursing, 6(12), 1–
13.