Nursing Care Plan #2 Acute pain
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Acute pain related to Short term: Independent: Independent: Short Term:
“Parang tumatagos po stab wound as evidence After 2 hours of nursing 1.Established rapport. 1. To gain the After 1 hour of nursing
yung sakit ng by agony of pain, SOB intervention the patient patient’s trust. intervention, patient
pagkasaksak sa akin” as and subscapular pain. will verbalized pain 2. Determined the 2. Aids in verbalized reduced pain
verbalized by the relief as manifested by location, evaluating need from pain scale of 8/10
patient. the decrease in the pain characteristics, onset, for and to 5/10.
scale of 5/10. duration, frequency, effectiveness of
quality, and severity of interventions.
Objective: Long term: pain via assessment. 3. To obtain Long Term:
BP: 140/90 After 8 hours of nursing baseline data After 8 hours of nursing
RR: 26 intervention, patient will 3. Monitored the vital and elevated intervention, patient was
PR: 91 b appear relaxed and able signs. vital signs may able to breath with
TR: 37.2 to sleep appropriately indicate that the normal pattern and
Pain scale: 8/10 with a pain scale of 3/10. 4. Positioned the patient client is absence facial grimace.
Patient displays in semi-fowler’s position experience pain. Vital signs were also
-facial grimace improved well-being if not contraindicated. 4. To promote lung normal with BP: 120/80;
-shortness of breath such as baseline levels expansion and RR: 20cpm; HR: 88bpm
for pulse, BP, 5. Encouraged used of decrease pain on and TR: 36.5.
respirations, and relaxed stress management the injured site.
body posture. techniques such as deep 5. Refocuses
breathing exercises. attention, may Goal was met
enhance coping
6.Investigated reports of abilities.
progressive or poorly 6. To monitor the
localized pain unrelieved progress of
by analgesics. recovery and
effectiveness of
interventions.
Dependent:
7. Administered Dependent:
medications, as 7. Many
indicated. medications and
8. Administered routes of
oxygen therapy administration
as ordered. may be used.
9. Assisted 8. To provide
performing adequate oxygen
thoracotomy. in the body
10. Assisted which increases
performing blood flow thus
thoracotomy relieving pain.
9. To remove air
and blood in the
pleural space
and promotes
lung expansion.
