NURSING CARE PLAN

Patient’s Initials: A, AJ.M

Age: 24 y/o
Sex: Male

Cues / Needs Nursing Diagnosis Rationale Goal and Interventions Rationale Evaluation
Objectives
Subjective data: Acute pain related Acute pain to After 1 hour of Independent: After 1 hour of
“Masakit ang likod to nerve unpleasant nursing intervention, - Assess verbal/ - useful in nursing
ko” as verbalized by compression as sensory and client will able to nonverbal reports evaluating pain, intervention, goal
the client. evidenced by: emotional of pain noting choice of
decrease pain from was met. Client
Pain range 8/10 as experience arising location, intensity intervention,
10 being the highest. - Presence of from actual or 8/10 to 4/10 as and duration. effectiveness of was able to
facial potential tissue manifested by: therapy. decrease pain
grimace damage or - Promote quite - to promote from 8/10 to 4/10
- Protective described in terms - Report pain is and calm adequate rest and as manifested by:
movement of such damage controlled environment. sleep to facilitate
- Restlessness the client is - Relaxed or pain relief. - Report pain
- Lower back experiencing calm - Monitor V/S - to monitor is controlled
Objective data: pain pain. every 4 hrs. proper V/S. - Relaxed or
- Presence of - Vital signs calm
facial of: Dependent:
grimace BP – 120/80 - Administer - reduces pain
- Protective PR – 79 analgesics or and discomfort,
movement RR – 20 dolcet (1 tab) as enhance rest.
- Restlessness T – 37.4 needed.
- Lower back
pain Interdependent:
- Vital signs - Provide for - helps to
of: individualized refocus attention
BP – 120/80 Reference: physical and assist client
PR – 79 Nurse’s Pocket therapy/exercise to manage pain
RR – 20 Guide (pp. 498- program that can or discomfort
T – 37.4 503) be continued by more effectively.
the client after
discharge.