Nursing Care Plan

Assessment Nursing Planning Interventions Rationale Evaluation

Diagnosis

Subjective Data: Acute pain related to
physical and biological
 On a scale of 1-10
client indicated evidenced by facial
pain was an 8. grimacing and reports
 Aching
 Throbbing
 Persistent
 Nausea
Objective Data:
 Sheilded Chest
 with hands
 Restlessness
 Pallor
 Client was
distracted and
unable to answer
some question.
Short Term: Assess pain The Client’s self report The goal is met.
Characteristic (Sharp, is the single most
injury agents as Constant, Stabbing) Ask reliable indicator of Client reported relief
Client will express
patient regarding level of pain. from pain within 30
relief from pain within
location or intensity of minutes of medication
30 minutes of
pain. pain. administration.
medication
Systematic, ongoing
administration. Client
Discuss with client’s assessment and Client described past
will describe past
past experiences with documentation provide experiences with pain,
experiences with pain
pain and effectiveness direction for the pain effectiveness of
and effectiveness of
of medications and side treatment plan. treatment methods and
methods used to
effects. a level at which she
manage pain, including
Providing comfort to could perform activities
experiences with side
Provide comfort the client helps to of daily living.
effects. Client will
measures: Back rub, lessen the pain.
communicate a
comfort-function goal. position changes, quiet
music, massage.
Long Term: Encourage use of
relaxation and breathing
Client will function on exercises.
acceptable ability level
with minimal
interference from pain Monitor Vital Signs.
and medication side
effects. Dependent:
Administer medication
as ordered.
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