NURSING CARE PLAN

Cues Nursing Background Goals Nursing Intervention Rationale Evaluation

Diagnosis Knowledge
(Subjective or
Objective data)
Long Short Term Ideal Actual
Term
Subjective: Acute pain Acute pain is the After 2 hours of  Assess pain  To determine pain After 2 hours of
related to state in which an nursing with the use intensity and nursing interventions,
 Sharp pain in spinal nerve individual interventions, the of pain rating description the goals were
lower back inflammation experiences and client will: scale (0-10). achieved as evidenced
and swelling reports the by:
● Report
as evidenced presence of severe  Aids in relieving
relief/control  Verbalization
by sharp pain discomfort or an  Place in a muscle fatigue and
of pain, of pain relief,
in lower back uncomfortable comfortable/ discomfort
sensation lasting  Identification
● Verbalize desired
from 1 second to of the methods
methods that position as
less than 6 months. that provide
provide indicated.
In a herniated disc, relief, and
relief, and  Promote the
the pain is a result  Provides comfort  Demonstration
● Demonstrate use of
of spinal nerve and sense of well- of the use of
the use of relaxation
inflammation and being relaxation
relaxation techniques
swelling caused by techniques.
techniques. like deep
the pressure of the breathing
herniated disc. and
visualization.
  To relieve pain
 Administer
pain
medications
as prescribed,
such as
acetaminoph
en,
ibuprofen, or
naproxen
sodium.
 Notify the
physician if
untoward
signs appear.

 To provide
immediate
intervention

Cues Nursing Background Goals Nursing Intervention Rationale Evaluation

Diagnosis Knowledge
(Subjective or
Objective data)
Long Short Term Ideal Actual
Term
Subjective: Impaired Impaired physical After 16 hours of  Educate  Reduces risk of After 16 hours of
physical mobility is the state nursing proper body muscle strain, nursing interventions,
 Stated failed mobility in which an interventions, client mechanics injury, and pain the goals were met as
attempt of lifting related to pain individual has a will:  Encourage  Patient evidenced by:
heavy materials and limitation in participation participation
 Exhibit  Verbalization
 Verbalization of limitations independent, in ADLs promotes
willingness of willingness
“Hirap na rin imposed by purposeful physical within independence and
to improve to improve
ako bumangon the condition movement of the individual sense of control
mobility and mobility and
sa kama." as evidenced body or of one or limitations  Strengthens spine
muscle muscle
by decreased more extremities. and promotes good
strength, strength,
muscle body mechanics
A modification in  Demonstrate  Demonstration
strength and  Provide and
movement or techniques of techniques
poor bed assist with
mobility can be that enable that enable
mobility passive and
caused by pain and doing ADLs, doing ADLs,
existing conditions active ROM
 Demonstrate  Demonstration
such as herniated exercises as
techniques . of techniques
disc. Mobility is indicated  To promote
that increase that increase
needed especially muscle  Promote movement since muscle
if an individual is strength, and progressive activity is limited strength, and
to maintain ambulation
 Increase the  Improvement
independent living. according to
strength and in performing
Limited movement individual
function of the activities
affects the tolerance  To obtain data in
the affected for increasing
performance of body part.  Document determining muscle strength
most ADLs. relevant client’s progress and mobility.
findings towards increasing
especially in muscle strength
performing and mobility
the activities