BUKIDNON STATE UNIVERSITY

COLLEGE OF NURSING
Malaybalay City, Bukidnon
NURSING CARE PLAN
Date Formulated:
Problem (PE Format: Acute pain and discomfort related to leukocyte infiltration of systemic tissues, fever, and infection.
Level of Prioritization: high

CUES DESIRED OUTCOMES INTERVENTIONS RATIONALE EVALUATION

Subjective SHORT TERM: INDEPENDENT SHORT TERM:

After 2 hours of nursing 1. Perform a 1. Alternatively, you After 2 hours of nursing

interventions the patient comprehensive can use the nursing interventions the Patient
demonstrates the use of assessment of pain. mnemonic “PQRST” displays improvement in
appropriate diversional Determine via to help guide your mood, coping.
activities and relaxation assessment the during pain
OBJECTIVE : skills location, assessment.
characteristics, onset, LONG TERM:
 Bone pain. duration, frequency,
 Fever. quality, and severity After 5 hours of nursing
 Frequent of pain. intervention the patient
infections. LONG TERM: 2. Pain should be uses pharmacological
 Frequent or screened every time and nonpharmacological
After 5 hours of nursing
severe vital signs are pain-relief strategies as
intervention the Patient
nosebleeds. evaluated. 2. pain assessment as evidenced by normal
displays improved well-
 Lumps caused the “fifth vital sign” body temperature and
being such as baseline
by swollen 3. Pain assessments must to pain assessment to normal breathing
levels for pulse, BP,
lymph nodes be initiated by the routine vital signs pattern.
respirations, and relaxed
in and around nurse. assessment
muscle tone or body
 the neck, posture 3. Pain responses are
underarm, unique from each
. GOAL PARTIALLY
abdomen or person and some
MET
groin. clients may be
 Pale skin. reluctant to report or
 Shortness of 4. Use the Wong-Baker voice out their pain
breath. FACES Rating Scale to unless asked about it.
determine pain 4. Some clients (e.g.,
intensity children, language
constraints) may not
be able to relate to
numerical pain scales
may need to use the
Wong-Baker Faces
Rating Scale.

5. Determine the
patient’s anticipation 5. patients may be
for pain relief. satisfied when pain is
no longer massive;
others will demand
complete elimination
of pain.

6. The meaning of pain

will directly
6. Evaluate what the
determine the
pain suggests to the
patient’s response.
patient.
7. provide an analgesic
before the onset of
 pain or before it
becomes severe when
7. Provide measures to
a larger dose may be
relieve pain before it
required.
becomes severe.

8. Nonpharmacologic
methods in pain
management may
include physical,
cognitive-behavioral
DEPENDENT/ strategies, and
COLLABORATIVE lifestyle pain
management.
8. Provide
9. or mild pain (1 to 3
nonpharmacologic
pain rating), the
pain management.
WHO analgesic
ladder suggests the
use of nonopioid
analgesics with or
without coanalgesics.

10. The effectiveness of

pain medications
9. Provide must be evaluated
pharmacologic pain individually by the
management as patient since they are
 ordered. absorbed and
metabolized
differently.

10. Evaluate the

effectiveness of
analgesics as ordered
and observe for any
signs and symptoms
of side effects.