Nursing Care Plan CUES SUBJECTIVE CUE: Tan buyong yo pati ta dwele dimiyo tangkugo tiene bes si kabar
hace trabaho na casa. Halos kada denoche, tan cramps dimiyo pyes. as verbalized by the client. OBJECTIVE CUES: Non adherence to treatment regimen T- 36.8 C P- 88 bpm R- 23 bpm 150/100 mmHg NURSING DIAGNOSIS Pain related to movement of bone ends, muscle spasms and traction. DESIRED OUTCOMES AT THE END OF 24 HOURS NURSEPATIENT INTERACTION AND INTERVENTION, CLIENT WILL BE ABLE TO: 1. Verbalize minimized or controlled feeling of pain 2. Verbalize methods that provide relief of pain INTERVENTIONS 1. Maintain immobilization of affected part by means of bedrest, cast, splint, and traction. 2. Elevate and support injured extremity. RATIONALE Relieves pain and prevents bone displacement/extensio n of tissue injury. IMPLEMENTATION Kept extremity immobile and traction in proper place. EVALUATION AT THE END OF 24 HOURS NURSEPATIENT INTERACTION AND INTERVENTION: Client will _________. Promotes venous return, decreases edema, and may reduce pain. Influences choice of, and monitors effectiveness of, interventions. Many factors, including level of anxiety, may affect perception of and reaction to pain. Note: Absence of pain expression does not necessarily mean lack of pain. Placed affected extremity on top of folded blankets.
3. Demonstrate use of relaxation skills and diversional activities
3. Evaluate and document reports of pain or discomfort, noting location and characteristics, including intensity (scale of 010), relieving, and aggravating factors. Note nonverbal pain cues, such as changes in vital signs and emotions or behavior. Listen to reports of family member/significan
Assessed and documented clients level of pain or discomfort, noting location and characteristics, including intensity (scale of 010), relieving, and aggravating factors. Observed and documented nonverbal pain cues, such as changes in vital signs and emotions or behavior. Asked family member/significant other (SO) regarding
t other (SO) regarding clients pain. 4. Encourage client to Helps alleviate anxiety. discuss problems Client may feel need to related to injury. relive the accident experience. 5. Explain procedures before beginning them. Allows client to prepare mentally for activity and to participate in controlling level of discomfort. Promotes muscle relaxation and enhances participation.
clients pain.
Encouraged client to verbalize feelings, needs and problems.
Explained every nursing procedure to be done to the client before doing it.
6. Medicate before care activities. Let client know it is important to request medication before pain becomes severe. 7. Perform and supervise passive or active ROM exercises.
Administered prescribed analgesic drugs.
Maintains strength and Taught client to mobility of unaffected perform passive and muscles and facilitates active ROM exercises. resolution of inflammation in injured tissues. Refocuses attention, promotes sense of Encouraged client to verbalize feelings and
8. Provide emotional support and
encourage use of stress managements techniques progressive relaxation, deepbreathing exercises, and visualization or guided imagery; provide therapeutic touch.
control, and may enhance coping abilities in the management of the stress of traumatic injury and pain, which is likely to persist for an extended period.
used verbal therapeutic techniques when conducting nurse-patientinteractions. Encouraged use of stress managements techniques like progressive relaxation, deepbreathing exercises, and visualization or guided imagery.
