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Nursing Care Plan: Assessment Diagnosis Inference Goal Intervention Rationale Evaluation

The nursing care plan addresses an acute pain related to inflammation in a client's back. The plan includes assessing the client's pain level, monitoring vital signs, using pillows and splints to rest the painful area, encouraging relaxation techniques to manage pain, engaging the client in diversional activities, administering prescribed analgesics, and evaluating the effectiveness of the interventions. The goal is to reduce the client's pain level to an acceptable amount within 3-4 hours using selected nursing interventions.

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Sugar Capule - Manuel
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© © All Rights Reserved
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162 views

Nursing Care Plan: Assessment Diagnosis Inference Goal Intervention Rationale Evaluation

The nursing care plan addresses an acute pain related to inflammation in a client's back. The plan includes assessing the client's pain level, monitoring vital signs, using pillows and splints to rest the painful area, encouraging relaxation techniques to manage pain, engaging the client in diversional activities, administering prescribed analgesics, and evaluating the effectiveness of the interventions. The goal is to reduce the client's pain level to an acceptable amount within 3-4 hours using selected nursing interventions.

Uploaded by

Sugar Capule - Manuel
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE GOAL INTERVENTION RATIONALE EVALUATION


Subjective:
Reports of
pain/discomfort.
Sumasakit na po
ang likod ko. With
pain scale of 8/10

Objective:
-Facial grimace of
pain.
-Narrowed focus.
-Distraction
behaviors
-Fatigue
Acute pain
related to
Inflammatory
responses as
manifested by:

Subjective:
Reports of
pain/discomfort.
Sumasakit na po
ang likod ko. With
pain scale of 8/10

Objective:
-Facial grimace of
pain.
-Narrowed focus.
-Distraction
behaviors
Because of
Inflammation
and necrosis
from the
infection,
exudates and
Necrotic
material lead to
increased pressure
within the bone
with eventual
abscess formation.
The abscess can
eventually drain
from the tract and
drain through the
skin. (Orthopedic
Nursing Secrets by
Michael E.
GOALS:
In 3-4 hours of
duty, after the
selected nursing
interventions the
client would be
able to alleviate or
reduce the pain
that is accepted by
the client.


OBJECTIVE:

After 30 minutes
of discussion,
the importance in
following
prescribed
Independent:
1. Investigate
reports of pain,
noting location
and intensity
(scale of 0-10).
Note
precipitating
factors and
nonverbal cues.
2. Monitor Vital
Signs
3. Place/monitor
use of pillows,
sandbags,
trochanter rolls,
splints, braces.



1. Helpful in
determining
pain
management
needs and
effectiveness of
program.


2. To obtain
Baseline Data
3. Rests painful
joints and
maintains
neutral position.
Note: Use of
splints can
decrease pain
Was the client able
to identify the
importance of
following the
prescribed
pharmacological
regimen?
_X_Yes _No

Was the able to
demonstrate at
least 3 relaxation
and diversional
activities in
controlling pain?
_X_Yes _No

Was the client able
to verbalize his/her
-Fatigue Zychowics page
83)
pharmacological
regimen.
After 30 minutes
of
demonstration,
the client would
be able to
identify at least
three (3)
relaxation
techniques and
diversional
activities in
controlling pain.
After 30 minutes
of discussion,
the client would
be able to
verbalize
thoughts about
her current
health status








4. Encourage use
of stress
management
techniques, e.g.,
progressive
relaxation,
biofeedback,
visualization,
guided imagery,
self-hypnosis,
and controlled
breathing,
provide
therapeutic
and may reduce
damage;
however,
prolonged
inactivity can
result in loss of
joint
mobility/function
4. Promotes
relaxation,
provides sense
of control, and
may enhance
coping
capabilities.







current health
status?
_X_Yes _No

touch.
5. Involve client in
diversional
activities
appropriate for
individual
situation.



6. Provide an
opportunity for
clients to
express their
own words how
they view the
pain and the
situation.
Dependent:
1. Administer
prescribed
analgesics and

5. Refocuses
attention,
provides
stimulation, and
enhances self-
esteem and
feelings of
general well-
being
6. This will help
the nurse
understand
what the pain
means to the
client and how
the client is
coping with it.

1. The nurses
assess the
patients
observe for pain
relief, side
effects.
response to
each
medication. As
the acute pain
subsides,
medications are
reduced as
prescribed

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