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La Salle University Nursing Care Plan

The nursing care plan summarizes a patient presenting with back pain related to pregnancy. The patient reported a pain level of 7/10. The plan outlines nursing diagnoses, interventions, and desired outcomes over 8 hours. Interventions included monitoring vitals, encouraging rest, applying warm compresses, educating on pain relief, and positioning for comfort. The desired outcomes were for the patient to report reduced pain levels, move comfortably, and experience pain relief without frequent occurrences. After 8 hours of care, the patient reported a pain level of 3/10 and was able to move comfortably while experiencing pain relief.

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Kristine Nacua
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2K views2 pages

La Salle University Nursing Care Plan

The nursing care plan summarizes a patient presenting with back pain related to pregnancy. The patient reported a pain level of 7/10. The plan outlines nursing diagnoses, interventions, and desired outcomes over 8 hours. Interventions included monitoring vitals, encouraging rest, applying warm compresses, educating on pain relief, and positioning for comfort. The desired outcomes were for the patient to report reduced pain levels, move comfortably, and experience pain relief without frequent occurrences. After 8 hours of care, the patient reported a pain level of 3/10 and was able to move comfortably while experiencing pain relief.

Uploaded by

Kristine Nacua
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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NRLE FORM - 10

La Salle University
College of Nursing
Ozamiz City
NURSING CARE PLAN
ASSESSMENT NURSING DESIRED OUTCOME INTERVENTION with RATIONALE EVALUATION
DIAGNOSIS
Subjective Data: Back pain related to After 8 hours of 1. Monitor vital signs. 1. Notes progress and changes of After 8 hours of
pregnancy as comprehensive nursing condition. comprehensive nursing
Patient complains evidenced by a pain intervention, the patient intervention, the patient
back pain. rating of 7/10. will be able to: 2. Encourage the client to 2. To promote calmness and was able to:
have bed rest. comfort to the client and reduces
 Report pain scale from 7 pain and anxiety.  Report pain scale
out of 10, to 3 out of 10 from 7 to 3 out of 10.
3. Advise the client to wear 3. To reduce the risk of spinal
Objective Data:  Move and rest flat or shoes with low heels. curvature necessary to maintain  Moved and rested
comfortably an upright position. comfortably
 Pain scale of
7/10  Control and experience 4. Apply warm compress on 4. Heat therapy works by relaxing  Controlled and
 Vital signs: relief of pain the area. the muscles increasing blood flow experienced relief of
BP: 110/90 and easing pain. pain
mmHg  Improve the client’s
Temp: 35.3˚C 5. Asses the characteristics of 5. Assessing the pan can help to
feeling and the pain will  Improved the client’s
RR: 20 cpm the pain, including the avoid any complications. Asking
not occur frequently feeling and the pain
HR: 98 bpm location, duration, the client to rate the pain helps will not occur
FHB: 144bpm intensity. Ask the client to to differentiate the previous and frequently
rate the pain from the scale current pain patterns.
of 1-10 and document the
findings.

6. Provide helping position 6. To alleviate the pain by


of comfort and suggest promoting non- pharmacological
use of relaxation pain management.
technique and deep

LA SALLE UNIVERSITY COLLEGE OF NURSING Nursing Care Plan 2019


breathing exercise.
Provide comfort such as
repositioning or quiet
environment.

7. Advise the significant 7. In order for the client to move


other to always assist the comfortably and not to have any
client when walking or difficulty.
standing or leaning.
8. Educating the client helps them
8. Educate the client by
to do things independently
giving information about
without going to the hospital.
pain relief measures
without any medication
needed and non-invasive
techniques.

Submitted by: Submitted to:

Name of Student: _Louise Kristine E. Nacua_ Ms. Sally Diangca


Year Level: BSN-4 Name of Clinical Instructor
Date: 05-05-2022 Date: 05-05-2022

LA SALLE UNIVERSITY COLLEGE OF NURSING Nursing Care Plan 2019

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