STUDENT NURSE’S NAME: L.

SUMALPONGFSUUSN Date: February 22, 2021

Client’s Name: Therese Age: 8-year-old

NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS EVALUATION

Subjective cues:
Objectives cues:
Crying
Acute pain related to muscle spasms Short term Goal:
as evidenced by expression of pain After 8 hours of nursing
through crying. interventions the patient will:
-Verbalize pain at a level less than 3
to 4 on a rating scale of 0 to 10.
-Display improved well-being such
as baseline levels for pulse, BP,
respirations, and relaxed muscle
tone or body posture.
Long term Goal:
After a month of nursing
interventions the patient will:
1. Assess and record the patient’s Short term Goal:
level of pain utilizing pain intensity After 8 hours of nursing
rating scale including Wong Baker interventions the patient is able to:
FACES pain rating scale, visual
analog scale, and FLACC scale. Note -Verbalize pain at a level less than 3
relieving and aggravating factors, to 4 on a rating scale of 0 to 10.
and nonverbal pain cues such as
changes in vital signs, emotions, and-Display improved well-being such
behavior. as baseline levels for pulse, BP,
respirations, and relaxed muscle
Rationale: Influences the tone or body posture.
effectiveness of interventions. Many
factors, including the level of
anxiety, may affect the perception Long term Goal:
of pain. After a month of nursing
interventions the patient is able to:

-Use pharmacological and 2. Maintain immobilization of -Use pharmacological and

nonpharmacological pain-relief affected part by means of bed rest, nonpharmacological pain-relief
strategies. cast, splint, traction. strategies.

Rationale: Relieves pain and

prevents bone displacement and
extension of tissue injury.

3. Evaluate pain regularly (every 2

hrs. noting characteristics, location,
and intensity. Emphasize patient’s
responsibility for reporting pain/
relief of pain completely.

Rationale: Provides information

about need for or effectiveness of
interventions. Note: It may not
always be possible to eliminate
pain; however, analgesics should
reduce pain to a tolerable level.

4. Explain procedures before

beginning them.

Rationale: Allows patient to prepare

mentally for activity and to
participate in controlling the level of
discomfort.

5. Assess vital signs, noting

tachycardia, hypertension, and
increased respiration, even if
patient denies pain.

Rationale: Changes in these vital

signs often indicate acute pain and
discomfort. Note: Some patients
may have a slightly lowered BP,
which returns to normal range after
pain relief is achieved.

6. Assess causes of possible

discomfort other than operative
procedure.

Rationale: Discomfort can be caused

or aggravated by presence of non-
patent indwelling catheters and
tubes.

7. Provide additional comfort

measures: backrub, heat or cold
applications.

Rationale: Improves circulation,

reduces muscle tension and anxiety
associated with pain. Enhances
sense of well-being.

8. Perform and supervise active and

passive ROM exercises.

Rationale: Maintains strength and

mobility of unaffected muscles and
facilitates resolution of
inflammation in injured tissues.

9. Encourage use of relaxation

techniques: deep-breathing
exercises, guided imagery,
visualization, music.

Rationale: Relieves muscle and

emotional tension; enhances sense
of control and may improve coping
abilities.

10. Evaluate the patient’s response

to pain and management strategies.
Rationale: It is essential to assist
patients to express as factually as
possible (i.e., without the effect of
mood, emotion, or anxiety) the
effect of pain relief measures.