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.