CHINESE GENERAL HOSPITAL COLLEGE OF NURSING Nursing Care Plan Patient’s Name:
R.V.F
ASSESSMENT
Subjective: “Sumasakit ung kaliwang tyan ko tapos nararamdamn ko siya hanggang sa kanang tyan ko”, as verbalized by the client Objective: Facial grimace was noted Level of pain was 8 out of 10 Slowed movement On CBC, WBC is increases (18.6 )
Acute pain is described as an unpleasant sensory or emotional experience associate with actual or potential tissue damage or injury as lasting from seconds to six months.
Short-term: After 30 minutes of nursing intervention, the patient will be able to gain knowledge in relieving pain as evidenced by: expected outcome:
1.Provide rapport with the patient
1.To gain trust and full cooperation during the pain alleviation periods
2. Monitor vital signs
2. Vital signs altered during acute pain
1. Enumerate 3 ways on how to relieve pain such as: Deep breathing exercises Proper positioning Adequate rest periods
RATIONALE
3. Provide a therapeutic environment
3. To aid in alleviation of pain
4.Encourage verbalization of feelings
4. To assist in evaluation
5. Encourage to do diversional activities
5.To alleviate pain
6. Encourage rest and sleep
6. To assess in alleviation of pain and to prevent fatigue. 7. Promotes active, not passive, role and
2. Decrease level of pain from 8 to 2
Short-term: After 30 minutes of nursing intervention, the patient will be able to gain knowledge in relieving pain as evidenced by: expected outcome: 3. Enumerate 3 ways on how to relieve pain such as: Deep breathing exercises Proper positioning Adequate rest periods
EVALUATION EVALUATION
7. Provide for individualized physical
4. Decrease level of pain from 8 to 2
Long-term: After 8 hours of nursing care, the client will be able to: Express alleviation of pain from 8 to 0 Absence of facial grimace
therapy or exercise program that can be continued by the client after discharge.
enhances sense of control.
Long-term: After 8 hours of nursing care, the client will be able to: Express alleviation of pain from 8 to 0 Absence of facial grimace
CHINESE GENERAL HOSPITAL COLLEGE OF NURSING Nursing Care Plan Patient’s Name: