HOLY‌‌‌NAME‌‌‌UNIVERSITY‌‌‌ 

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COLLEGE‌‌‌OF‌‌‌HEALTH‌‌‌SCIENCES‌‌‌ ‌
NURSING‌‌‌DEPARTMENT‌‌‌ ‌
City‌‌‌of‌‌‌Tagbilaran‌‌‌ ‌
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NURSING‌‌‌CARE‌‌‌PLAN‌‌ ‌

Name of Patient: Richard Simons Age: 45 Status: Single Address: Date of Admission: May 2, 2022 Ward: Surgical Ward Bed No. 1
Impression: Bone Fracture_______________

ASSESSMENT PLANNING INTERVENTIONS

PROBLEM CUES/ NURSING RATIONALE OF THE BEHAVIORAL OUTCOME(S)

DESIRED OUTCOME(S) NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS PROBLEM

-Acute Pain related to bone The patient is - After 3 days of - After 6 hours of - Independent: - The goal was met; the
fracture as evidenced by: experiencing acute pain patient was able to
Nursing Intervention, Nurse-Patient
in the case of a bone 1. Note location of surgical  this can influence the report that pain was
fracture due to variety the patient will be interaction, the procedure amount of relieved or controlled
Subjective data: of reasons: The nerve postoperative pain as evidenced by a
endings that surround able to report pain is patient will be able to: experienced; for decrease in the pain
Patient complained of pain bones contain pain relieved or controlled. example, vertical or scale rating from 6/10
1. Verbalize
at the surgical site fiber. These fibers may diagonal incisions are to 2/10.
nonpharmacological more painful than
with a pain scale of 6/10 become irritated when methods that provide transverse or S-shaped.
the bone is broken or relief. Presence of known or
bruised. Broken bones unknown
Objective data: bleed, and the blood 2. Demonstrate use of complication(s) may
and associated swelling relaxation skills and make the pain more
- changes in blood (edema) causes pain. diversional activities, as severe than
pressure, heart rate, and Muscles that surround indicated, for individual anticipated.
2. Obtain client’s/SO’s
respiratory rate the injured area may go situation. assessment of pain to
into spasm when they include location,  in order to fully
-restlesness
try to hold the broken characteristics, onset, understand client’s
dcasquejo@hnu.edu.ph
 ASSESSMENT PLANNING INTERVENTIONS

PROBLEM CUES/ RATIONALE OF THE DESIRED BEHAVIORAL

NURSING INTERVENTIONS RATIONALE EVALUATION
NURSING DIAGNOSIS PROBLEM OUTCOME(S) OUTCOME(S)

Vital signs as follows: bone fragments in 3. Follow prescribed

place, and these spasms pharmacological duration, frequency, pain symptoms.
T- 36.8 C quality, intensity.
may cause further pain. regimen.
P- 76bpm Identify precipitating or
aggravating and
R- 16bpm relieving factors

BP- 120/90 3. Use pain rating scale

appropriate for age and
cognition

4. Instruct in and  To respond to the pain

encourage use of
appropriately
relaxation techniques,
such as focused
breathing, imaging,
CDs/tapes (e.g., “white”  to distract attention
noise, music, and reduce tension.
instructional

5. Provide comfort
measures (e.g., touch,
repositioning, use of
heat or cold packs,  to promote
nurse’s presence), quiet nonpharmacological
environment, and calm pain management.
activities

6. Note when pain occurs

dcasquejo@hnu.edu.ph
 ASSESSMENT PLANNING INTERVENTIONS
PROBLEM CUES/ RATIONALE OF THE DESIRED BEHAVIORAL
NURSING INTERVENTIONS
NURSING DIAGNOSIS PROBLEM OUTCOME(S) OUTCOME(S)
7. Establish collaborative
approach for pain
management based on
client’s understanding
about and acceptance of
available treatment
options.
Dependent:
1.Administer analgesics, as
indicated, to maximum
dosage, as needed
Collaborative:
1. Provide for individualized
physical therapy or exercise
pro- gram that can be
continued by the client after
discharge.
RATIONALE EVALUATION
 to medicate
prophylactically, as
appropriate.
 Pain medications may
include pills/ liquids or
suckers, skin patch, or
suppository forms;
injections, intravenous
dosing; or patient-
controlled
 to maintain
“acceptable” level of
pain. Notify physician if
regimen is inadequate
to meet pain control
goal. Combinations of
medications may be
used on prescribed
intervals.
 Promotes active, rather
than passive, role and
enhances sense of
dcasquejo@hnu.edu.ph
 ASSESSMENT PLANNING INTERVENTIONS

PROBLEM CUES/ RATIONALE OF THE DESIRED BEHAVIORAL

NURSING INTERVENTIONS RATIONALE EVALUATION
NURSING DIAGNOSIS PROBLEM OUTCOME(S) OUTCOME(S)

control.
2. Collaborate in treatment
of underlying condition or
disease processes causing
pain and proactive  To provide continuous
management of pain (e.g.,
pain management
epidural analgesia, nerve
blockade for postoperative
pain).

dcasquejo@hnu.edu.ph