Nursing Care Plan

NURSING PROBLEM
GOAL AND NURSING
AND CUES ANALYSIS RATIONALE EVALUATION
OBJECTIVES INTERVENTIONS

Acute pain related to actual Goal: 1.1 Obtain client’s 1.1 To rule out After an hour of
tissue damage assessment of pain to worsening of nursing
After an hour of include location, underlying condtion interventions the
Subjective: nursing characteristics, onset, and development of patient was able to
interventions duration, & precipitating condition. verbalize relief
“Masakit kapag ako ay the patient will and aggravating factors. from pain.
dumudumi.” As verbalized by verbalize pain is Note and investigate
the client. relieved/controlled changes from previous
as evidenced by: reports.
Objective:
- observed evidence of pain Objectives: 1.2 Use pain scale 1.2 To determine
- Facial mask, sleep disturbance appropriate for the severity of pain.
- Irritability 1. To evaluate age/cognition (e.g, pain
- Pain scale of 7 client’s response to assessment scale for
pain. elderly.

1.3 Accept client’s 1.3 Pain is a

description of pain. subjective
Acknowledge the pain experience and
and convey acceptance of cannot be felt by
client’s response to pain. others.

1.4 Observe non-verbal 1.4 Serves as an

cues or pain behaviors indicator when
such as facial client is unable to
expressions especially to verbalize and
persons who cannot may/not be
communicate verbally. congruent with
verbal reports.
 1.5 Determine frequency 1.5 To know how
of bowel movement. long the problem
has been.

2. To assist client in 2.1 Determine client’s 2.1 Varies with

exploring methods acceptable level of pain. individuals and
for alleviation of situation.
pain.
2.2 Respond immediately 2.2 Reduces
to complaint of pain. anxiety and patient
and demonstrates
concern that helps
in fostering a
trusting
relationship.

2.3 Eliminate additional 2.3 Patients may

stressors or sources of experience an
discomfort as much as exaggeration in
possible. pain if another
stimuli are further
stressing them.

2.4 Administer analgesics 2.4 Analgesics

as ordered. reduce pain in
clients and doctors
must be notified if
regimen is unable
to meet pain
control.

2.5 Provide comfort 2.5 Promote non

measures (touch, pharmacological
repositioning, quiet management of
environment) pain.
3. To promote 3.1 Encourage adequate 3.1 To prevent
wellness. rest. fatigue.

3.2 Increase fiber intake. 3.2 Foods

container fiber
makes movement
of food and
elimination easier.

3.3 Drink 8-10 glasses of 3.3 Aids in

water everday. peristalsis, serves
as lubricant of the
intestines.
NURSING PROBLEM ANALYSIS GOAL AND NURSING RATIONALE EVALUATION
AND CUES OBJECTIVES INTERVENTIONS