PALAWAN STATE UNIVERSITY

COLLEGE OF NURSING AND HEALTH SCIENCES

Puerto Princesa City

NURSING CARE PLAN

CUES NURSING PATHOPHYSIOLOGY OBJE CTIVE EXPECTED INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS OUTCOME
Subjective Acute pain r/t Nociceptors generate pain At the end of 15- At the end of 15- After 30 minutes
“masakit ang Tiyan stomach mucous impulse 30 minutes of 30 minutes of 1. Accept client’s description of Pain is a subjective of nursing
ko.” membrane nursing nursing pain. experience and interventions,
 Pain scale of 8 damage and Travels along afferent intervention, intervention, cannot be felt by patient was able:
out of 10 (10 disease process neuron patient will be patient will be others.
as the worst) able to report able to: 1.1. Provide comfort measure To provide non-  Report has
Substantia gelatinosa that pain is (back rub). pharmacological pain declined to a
Objective release impulse to spinal reduced and (S) Demonstrate management. more
 Facial grimace cord tolerated. use of relation tolerable
 Weak technique to 1.2. Instruct in the use of Relieves muscle and rate. PS of 5
 Irritable Dorsal horn synapse relay minimize pain. relaxation techniques like emotional tension; out of 10.
 Moaning impulse to spinal cord deep breathing, music enhance sense of
therapy, diversional activities, control and may
Travels to the brain cortex and providing a calm and improve coping
quiet environment. ability.
Interpretation
1.3. Encourage to have adequate To prevent fatigue.
Pain perception rest.

2. Discuss to the mother several To enhance client’s

methods that may alleviate awareness on pain
pain such as: management.
Deep breathing  Relieves muscle
and emotional
tension.
Back rubbing
 Often used to
(K) Identify at Music therapy help a person  Identify three
 least three become more techniques
methods that relaxed. that would
provide relief for minimize pain
pain. such as:
 Music increases  Deep
Diversional blood flow to the breathing
activities/guided imagery. brain and helps  Back
you to take in rubbing
Providing calm and quiet more air. Music therapy
environment Scientists said
that it increases
energy and helps
2.1. Ask the patient to enumerate you change your
at least three ways that may mood.
help lessen the pain.  Helps divert
attention to other
3. Establish rapport with the things.
patient.

3.1. Encourage patient’s Being in a calm

participation in the plan of environment helps a
care. person relax.

(A) Maintain Acknowledge patient’s To evaluate if patient

positive attitude partnership with healthcare team. gained knowledge
towards the plan from you.
of care.
To gain patient’s trust
and cooperation.

To enhance patient’s
participation.

References: Nurses Pocket Guide