Nursing Care Plan

CUES NURSING DIAGNOSIS Acute pain related to severe headache as evidenced by high blood pressure, irregular heart rate, restlessness, nausea and vomiting, scattered movement and grimace ANALYSIS GOAL and OBJECTIVES Goal : After 1 hour and 10 minutes of nursing interventions the client will be able to verbalize or report pain is relieved or controlled. Objectives: 1. After 5 minutes of discussion, the client will be able to verbalize what acute pain means. INTERVENTION RATIONALE EVALUATION

Objective: BP 200/ 110 mmHg as of 10:35 am 170/130 mmHg as of 10:55 am Heart rate is irregular Pale looking Restlessness Dizzy Weaken Nausea Vomited twice Grimace Scattered movement

Acute Pain is unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage ( International Association for the Study of Pain); sudden or slow onset at any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months ( Nurses Pocket Guide

Supplemental:

EFFECTIVENESS

1. Discuss what acute pain is.

2. After 15 minutes of

2. Discuss effects

1. The meaning of the pain will directly influence the patients response. Some patients, especially the dying may feel that the act of suffering meets a spiritual need. (Nursing Diagnosis Care Plan, Chapter 14, pg. 146 by Gulanick Myers) 2. To promote ways to maximize level of

1. Was the client able to state the meaning of pain? Yes__ No__ Why? ________

2. Was the client able

Reduced interaction with people and environment

12th edition, pg. 586 by Doenges, Moorhouse and Murr. ) The Phenomenon of Pain

discussion the client will be able to enumerate the impact of pain on lifestyle.

of pain to lifestyle. functioning. ( Nurses Pocket Guide 12th edition, pg. 590by Doenges, Moorhouse and Murr.) 3. Discuss importance of adequate rest periods. 3. To prevent fatigue. (Nurses Pocket Guide 12th edition, pg. 590 by Doenges, Moorhouse and Murr.)

to enumerate effects of pain on lifestyle? Yes__ No__ Why? _________

3. After 10 minutes of discussion The gate client will be control theory, able to which was enumerate the proposed in importance of 1965, gained having wide adequate rest acceptance periods. and stimulated significant 4. After 10 clinical minutes of research discussion the related to pain client will be response and able to control. The enumerate theory suggest effects of that the alcohol or drug transmission use in the of painful response or stimuli can be choice of the modulated analgesics for through gating pain mechanism management. located in the substantia gelatinosa in the dorsal 5. After 5

3. Was the client able to state the importance of adequate rest periods? Yes__ No__ Why? _______

4. Discuss effects of alcohols and drug use to the choice and response of analgesics for pain management.

4. Factors in clients lifestyle can affect responses to analgesics or choice of interventions for pain management. ( Nurses Pocket Guide 12th edition, pg. 589 by Doenges, Moorhouse and Murr. )

4. Was the client able to enumerate effects of alcohol and drug use to the choice and response of analgesic for pain management? Yes__ No__ Why? ________

Developmental: 5. Ask the client about the pain 5. Was the client able to describe the pain

5. Pain is subjective

horn of the spinal cord. It is thought that activity in the peripheral and central nervous system could affect the opening and closing of the gate. Studies related to specific pain modulatory systems have supplemented the theorys description of pain transmission and enhanced understanding of the neural mechanisms underlying the variability of the pain experience. In addressing the variability of the experience, the patients perception of and reaction

minutes the client will be able to describe the pain she feels.

experience and response to pain.

experience and cannot be felt by others. ( Nurses Pocket Guide 12th edition, pg. 588 by Doenges, Moorhouse and Murr.) 6. To promote nonpharmacological pain management. ( Nurses Pocket Guide 12th edition, pg. 589 by Doenges, Moorhouse and Murr. )

she is experiencing? Yes__ No__ Why? ________

6. After 15 minutes of discussion and demonstration the client will be able to demonstrate comfort measures for pain. 7. After 10 minutes of discussion and demonstration the client will be able to demonstrate relaxation techniques to relieve pain.

6. Discuss and demonstrate different kinds of comfort measures.

6. Was the client able to demonstrate different kinds of comfort measures? Yes__ No__ Why? ________

7. Discuss and demonstrate different kinds of relaxation techniques.

7. To distract attention and reduce tension. ( Nurses Pocket Guide 12th edition, pg. 589 by Doenges, Moorhouse and Murr. )

7. Was the client able to demonstrate different kinds of relaxation techniques? Yes__ No__ Why? ________

to pain must also be considered. ( Cognitive Perceptual Pattern, pg. 512 by McGraw Hill Book Co. , Fields HL

EFFICIENCY Were resources available to the nurse and client maximized? Yes__ No__ Why? ________ APPROPRIATENESS Were interventions appropriate to client with severe headache? Yes__ No__ Why? ________ ACCEPTABILITY Were all interventions acceptable to the client? Yes__ No__ Why? ________ ADEQUACY Were the numbers of interventions enough to solve the health problem? Yes__ No__ Why? ________

FAR EASTERN UNIVERSITY INSTITUTE OF NURSING

NURSING CARE PLAN

Submitted by: MAYLS S. CALIZO BSN 301 Submitted to:
MRS JOANNE LOJO CLINICAL INSTRUCTOR

Nursing Care Plan

CUES

NURSING DIAGNOSIS

ANALYSIS

GOAL and OBJECTIVES

INTERVENTIONS

RATIONALE

EVALUATION