NURSING CARE PLAN

Cues Nursing Outcome Intervention Rationale Evaluation Discharge

Diagnosis Criteria Planning

Subjective Cues: - Acute pain Short Term: Independent: Short Term: M: Teach the patient
related to After 8 Hours of -Perform a Thorough assessment After 8 Hours of the importance of
Patient injuring agents Nursing comprehensive of pain will help the Nursing Intervention, taking his medication
complained secondary to Intervention, the assessment of pain health care provider the Client was able to regularly and follow
of Gout as Client will be include location, understand and manage the instruction of his
Generalize evidenced by able to characteristic, onset, the pain better as it  Verbalize relief physician.
d pain in Pain in right duration, frequency, provides more specific from pain and
right foot foot, ● Verbalize quality, intensity or discomfort E: Environment
data regarding the pain
in the sole, Tenderness, relief from pain severity, and should be calm.
Swelling over and discomfort precipitating factors.  Exhibit decreased Stressors or sources
lateral
lateral ankle (Use Pain assessment redness and of discomfort should
ankle and
malleolus and ● Exhibit a scale from 0-10 if inflammation of be avoided and
dorsum that
hot erythema decrease in R necessary) the Right Foot encourage rest
becomes Foot redness periods in between
over lateral
worse at aspect. and Eliminate additional Patient who are ADL
 Demonstrate use
night. inflammation stressors or other experiencing pain have of pain coping
sources of decreased ability to techniques such T: Teach the
● Demonstrate discomfort tolerate painful stimuli. as repositioning, patient effective
pain coping A stressful imagery, and timing of the
techniques breathing medication dose in
environmental,
interpersonal, or exercises relation to
Objective Data: potentially
Long Term: intrapsychic factors are
Long Term: uncomfortable
Clinical Examination After 2 Weeks further stresses. activities and the
After 2 Weeks of
Revealed of Nursing Nursing Intervention, prevention of peak
Intervention, the Encourage frequent the patient was able pain periods in
- Pain in right foot patient will be changes of position. Prevents general fatigue and to: order to minimize
able to: Assist the patient to joint stiffness. Stabilizes pain experiences.
- Tender, Swelling move in bed, joint, decreasing joint  Demonstrate
over lateral ● Demonstrate supporting affected movement and associated H: When doing
proper use of
ankle malleolus proper use of joints above and pain. activities, have rest
adaptive device
adaptive device to below, avoiding jerky periods to avoid
(crutches) to assist
- Hot, erythema improve mobility movements. straining the
in Mobility
over lateral recovering joint.
aspect. ●Demonstrate an Encourage the use of Promotes relaxation,  Exhibit an
increased strength stress management provides a sense of control Avoid doing
increased strength
or endurance of techniques such as and may enhance coping strenuous activities
and endurance of
injured limb abilities.
 progressive injured limb by and use an icepack if
Medical History relaxation, executing ADLs the injury feels
revealed: biofeedback, with no problem. painful or if swelling
visualization, guided occurs
- Left foot stress
imagery, self-
fracture 4th
hypnosis, and O: Instruct the
metatarsal
controlled breathing. Patient to follow
- Pt been Provide the schedule of his
weightbearing Therapeutic Touch physician for
on right foot for follow-up checkup
1/12 years Patient’s experiences of or contact
- Hypertension
Provide Rest Periods pain may become
to facilitate comfort, exaggerated as the result of
immediately if any
underlying signs
due Cholesterol sleep, and relaxation fatigue and exhaustion. A and symptoms
- Left shoulder quite environment, a
darkened room, are
occur.
replacement and
measures toward facilitating D: Teach the client
bone graft
rest about dietary
- Left knee modifications to
arthroscopy (3 limit foods high in
times) Providing measures that purine (e.g. organ
Promote measures to prevents exacerbation will meats, anchovies,
- (+) Allergy to prevent exacerbations lessen the risk of the patient sardines, shellfish,
Iodine worsening his condition. chocolate, meat
This includes Urging the extracts).also, avoid
patient to drink 2 to 3 L of or limit the
Laboratory Tests fluid daily and to report any consumption of
Revealed: decrease in urine output. alcohol
- C-Reactive S: Encourage the
Protein: 37.6 Family and friends
(elevated) - Antigout drug under the (Folks) to be there
Dependent: pharmacologic class with the patient and
-Administer colchicum autumnale support the patient’s
Medication as alkaloids. Involves a needs.
indicated reduction in lactic acid
produced by leukocytes,
- Colchicine 1mg reducing uric acid Spirituality:
TID deposits and Encourage
phagocytosis thereby the patient to
decreasing the do his prayers
inflammatory process and or rituals
depending on
his religion.
 - Antigout drug under the
pharmacologic class
Xantine Oxidase
Inhibitors. Reduces uric
acid production by
inhibiting xanthine
- Continue oxidase
Allopurinol
- NSAID under the
Pharmacologic Class
Salicylate. Thought to
produce analgesia and
exert its anti-
inflammatory effect by
inhibiting prostaglandin
- NSAIDs and other substances
(Aspirin) that sensitize pain
receptors.

Collaborative: A well balanced diet and

Refer to Nutritionist good nutrition can
and/or Dietitian supplement in the body’s
ability to recover from
illness

The use of an adaptive

Refer patient to device or modification of
Physical Therapist movement may assist the
client during hospital stay
and rehabilitation after
discharge

Prepared By: Czar Eli Antonio Manikan/Jan Genesis Makani BSN 3-E CPUCN

SOURCES:

https://www.rnpedia.com/nursing-notes/medical-surgical-nursing-notes/gouty-arthritis-nursing-management/
- 2017, Nursing Drug Handbook –An evidence based guide to planning care, 11th Edition, Elsevier.
- 2013, Lyndia Carpenito, Nursing Diagnosis-Application to clinical practice, 14 th edition, Wolters Kluwer
- Vera, M. (2019) “Rheumatoid Arthritis Nursing Care Plans” NurseLabs retrieved on May 10, 2021 from: https://nurseslabs.com/6-rheumatoid-arthritis-
nursing-care-plans/?fbclid=IwAR1-BipcGaAt5w5VLKplHKcMV3WtYor3AiKKNhgQch1_L9mTldetLlTHxS4