NURSING CARE PLAN
UNIVERSITY OF ILOILO
Name of Patient: ____________________________________
Chief Complaint: ____________________________________
Nursing Diagnosis
Acute pain related to disruption
of skin, tissue, and muscle
integrity.
Subjective:
“ Masakit yung tahi ko”
as verbalized by patient.
Objective:
• Facial mask of pain.
• Guarding behavior.
• Narrowed focus.
V/S taken as follows:
T: 37.3
P: 80 Bpm
R: 18 Cpm
Bp: 110/90 mmhg
Student’s Name: __________________________
COLLEGE OF NURSING
Age: ______________ Gender:______ Attending Physician: _____________________________________
Diagnosis: ____________________________________________________________________________
Plan / Goal Outcome Criteria Nursing Intervention
Independent:
After 8 Hours of nursing • Evaluate pain regularly nothing
interventions, the patient pain characteristics, location,
will be relieved or controlled. intensity (0-10 scale).
• Identify specific activity
limitations.
• Recommend planned or
progressive exercise.
• Adequate rest periods.
• Review importance of nutritious
diets and adequate fluid intake.
• Repositon as indicated.
• Provide additional comfort
measures like backrub.
• Encourage use of relaxation
technique like deep breathing
exercise.
Collaborative:
• Administer analgesics or
nonsteroidal anti-inflammatory
drugs as prescribed.
Rationale Evaluation
• Provides information about need for • After 8 hour hours
or effectiveness of interventions. of interventions,
Goals partially
• Prevents unduestrain on operative meet, the patient
site. pain was
• Promotes return of normal function minimize.
and enchances feelings of general
well being.
• Prevents fatigue and conserves
energy for healing.
• Provides elements necessary for
tissue regeneration or healing.
• May relieve pain and enchance
circulation.
• Improves circulation, reduces
muscle tension and anxiety
associated with pain.
• Relieves muscle and emotional
tension.
• To relieve mild or moderate pain.
Clinical Instructor: _______________________________
Year & Section: ____________________________________ Date Submitted: __________________________