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Nursing Care Plan for Acute Pain Management

1. The nursing care plan addresses acute pain related to tumor growth as evidenced by the client reporting a pain scale of 9/10. 2. Short term goals include decreasing the client's pain scale to 5-7 and respiratory rate to 20-30 cycles per minute after 1-2 hours of nursing intervention through comfort measures, relaxation techniques, and medication. 3. Long term goals aim to further decrease the client's pain scale to 3-5 and respiratory rate by 12-20 cycles per minute after 6-8 hours of continued nursing care.

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Rachel Tiangco
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29 views2 pages

Nursing Care Plan for Acute Pain Management

1. The nursing care plan addresses acute pain related to tumor growth as evidenced by the client reporting a pain scale of 9/10. 2. Short term goals include decreasing the client's pain scale to 5-7 and respiratory rate to 20-30 cycles per minute after 1-2 hours of nursing intervention through comfort measures, relaxation techniques, and medication. 3. Long term goals aim to further decrease the client's pain scale to 3-5 and respiratory rate by 12-20 cycles per minute after 6-8 hours of continued nursing care.

Uploaded by

Rachel Tiangco
Copyright
© Attribution Non-Commercial (BY-NC)
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

NURSING CARE PLAN

Assessment Nursing Scientific Goal of care Nursing Rationale Evaluation


Diagnosis rationale intervention

Subjective Acute pain Cell Damage Short term Independent: Short term goals:
cue: related to goals:
tumor growth Note when pain To medicate After 2 hours of
“oo masakit As evidenced Inflammatory After 1-2 occurs. prophylactically nursing
talaga sya by response hours of as appropriate. intervention the
mga 9/10” nursing client
as verbalized Subjective intervention Provide To promote
by the client cue: Vasodilation of the client comfort non- report decreased
( 1- lowest blood vessels measures. pharmalogical pain scale of 7
10 – highest) “oo masakit occurs Will report pain
talaga sya decreased management Respiratory rate
Objective mga 9/10” pain scale decreased down
cues: as verbalized Release of from 5-7 Instruct or To distract to 27 cycles per
by the client chemical encourage use attention and min.
Guarding ( 1- lowest 10 mediators Respiratory of relaxation reduce tension.
behavior – highest) (histamine & rate will technique such GOAL WAS MET.
kinins) decreased as focus
Positioning Objective atleast 20 – 30 breathing. Long term goals:
to avoid the cues: cycles per
pain Pain min. Encourage To prevent After 8 hours of
Guarding adequate rest fatigue. nursing
Sleep behavior Long term periods. intervention the
disturbance goals: client
Positioning to Reference: Assist client to To assist in
Irritable and avoid the Medical After 6-8 learn breathing muscle and
sighing pain -Surgical hours of techniques. generalized report same pain
Nursing by nursing relaxation. scale (7)
Respiratory Sleep William intervention
rate – 37 disturbance Lippincott the client
cycles/min. Page 92
NURSING CARE PLAN
Irritable and
Cardiac rate sighing Will report Review To reduce Respiratory rate
– 100bpm decreased procedures/exp concern of the decreased to 26
Respiratory pain scale ectations and unknown and cycles per min.
Temp. - rate – 37 from 3-5 tell client when associated
37°C cycles/min. treatment may muscle tension.
Respiratory cause pain. GOAL WAS NOT
Pulse rate – Temp. - 37°C rate will MET.
97 bpm decreased at Dependent:
Pulse rate – least 12-20
Blood 100 bpm cycles per Administer
pressure – min. Oxycontin
120/90 Blood (Analgesic,
mmHg pressure – opioid ) 1 tab
120/90 Will be able to Q12°
mmHg demonstrate
use of
relaxation
skills and
diversional
activities as
indicated, for
individual
Situation.

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