A Nursing Care Plan

ACUTE PAIN

In Partial Fulfillment of the Requirements on NCM 212 - RLE

IMMUNOLOGY / CANCER ROTATION

Submitted to:

MRS. MARILOU T. HERNANDEZ, RN, MN

CLINICAL INSTRUCTOR

MS. RAVEN MAYBANTING, ST.N

PRACTICING CLINICAL INSTRUCTOR

Submitted by:

JULLIANE PEARL J. CAHULOGAN

BSN 3L - GROUP 3

SEPTEMBER 18, 2022

 CLUSTERED DATA NURSING DIAGNOSIS PRIORITY

COPING-STRESS TOLERANCE PATTERN

- Patient verbalized, “Nurse nahadlok ko sa kung unsa man FEAR LOW PRIORITY - 1
ang akoang sakit kay sakit man gud kaayo akong bat.ang
basig naa koy cancer.” ANXIETY LOW PRIORITY - 2

COGNITIVE-PERCEPTUAL PATTERN

- Complained about pain in her flank and in urinating.

- She verbalized, “Sakit kaayo akong bat-ang ug akong
pus.on ba. Akong bat-ang kay murag gi pukpok ug martilyo ACUTE PAIN HIGH PRIORITY - 1
unya mudagan ang sakit pababa sa akong paa. Unya sakit
mangihi. Hapdos iihi.”
- When asked about how painful it is fromthe scal of 0-10, 0
being the lowest and 10 being the highest, she said 10/10.
 NURSING CARE PLAN

DATE/ CUES NEEDS NURSING DIAGNOSIS PATIENT OUTCOME NURSING INTERVENTION IMPLICATION EVALUATION
TIME

S Subjective cues: C Acute Pain related to After 8 hours of nursing 1. Document the patient’s level of pain. 1 S
E O hematuria as evidenced by intervention, the client will be Note for any signs of elevated vital E
P Complained about pain G pain scale of 10/10 and expected/ able to: signs (e.g., Temperature, Pulse rate, P
T in her flank and in N verbalized pain in the flank and Respiration rate, Blood pressure, etc.). T
E urinating. I burning pain upon urination. a) Verbalize acceptable level Observe for verbal and nonverbal cues. E
M T of pain relief and ability to M
B She verbalized, “Sakit I Rationale: Patients with engage in desired activities. R: Documenting will be helpful in B
E kaayo akong bat-ang ug V hematuria may have other monitoring the progress and in E
R akong pus.on ba. Akong E symptoms of urinary tract b) Reports pain at a level less determining the effectiveness of the R
bat-ang kay murag gi disorders such as, pain in side than 3 to 4 on a 0 to 10 rating regimens given to the patient. Pain
1 pukpok ug martilyo unya - or back (flank), lower scale. significantly affects the vital signs of the 1
8 mudagan ang sakit abdominal pain, urgent need to patient especially the pulse rate, 8
pababa sa akong paa. P urinate, or difficulty urinating. c) Maintain normal vital signs. respiration rate, temperature, and blood
2 Unya sakit mangihi. E pressure. Severe pain causes irritation 2
0 Hapdos iihi.” R Maddukuri, G. (2022, August d) Engages in desired and restlessness in the patient. 0
2 C 22). Blood in Urine. MSD activities without an increase 2
2 Objective cues: E Manual Consumer Version. in pain level. 2. Record and monitor the patient’s vital 2 2
P Retrieved September 18, signs.
@ Pain scale of 10/10 T 2022, from @
U https://www.msdmanuals.com/ R: Recording and monitoring the vital
7 VS: A home/kidney-and-urinary-tract- signs of the patient will provide baseline 3
A T: 37.4 (Normal L disorders/symptoms-of-kidney- data for monitoring the progress and P
M Axillary: 36.5-37.0) and-urinary-tract-disorders/urin detection of new signs. M
PR: 100 (Normal: P e-blood-in
60-80bpm) A 3. Apply heating pad to the site of pain “GOAL IS MET”
HR: 102 ((Normal: T (e.g., Flank and lower abdomen) 3
60-80bpm) T R: Application of heat relieves pain by After 8 hours of nursing
RR: 26cpm (Normal: E relaxing the muscles and reducing its intervention, the client
16-20cpm) R spasms was able to :
N
LAB RESULTS: 4. Encourage patient to increase clear 4 a) Verbalize an
CBC: fluid intake unless contraindicated. acceptable level of pain
○ Hgb: 80 (Normal: Instruct patient to avoid dark beverages relief and was able to
115-160) and alcohol. engage in desired
WBC: 10.4 activities (e.g., Walking to
○ Hct: 0.63 (Normal: R: Adequate fluid intake increases the bathroom without
0.37-0.47) urine production and dilution, reduces assistance.)
○ Plt: 148 (Normal: inflammation, promotes renal blood
150-400) flow, and flushes bacteria that cuses b) Reported pain at a
infection. Dark beverages causes level 3/10.
○ Creatinine: 1.15 discoloration of urine thus, difficult to c.) Maintained normal
mg/dL (Normal: distinguish the presence of gross vital signs.
0.59-1.04) hematuria.
d.) Engaged in desired
Patient is seen pale and 5. Encourage patient to frequently void 5 activities without an
sweating. and take note of the urine increase in pain level.
characteristics.
Face is also in grimace.
R: Frequent voiding empties out the
Came in d/t hematuria. bladder to reduce distention and stasis
preventing re-infection.

6. Educate patient of 6
nonpharmacological pain management.

R: Techniques like guided imagery,

massage, and distraction techniques
are just some of the
JP CAHULOGAN, St.N
nonpharmacological managements that
decreases pain and promotes comfort
and relaxation to the patient.

7. Administer medication such as 7

analgesics and antibiotics as ordered.

R: Analgesics are for reducing the pain

and antibiotics resolve the current
infection of the patient.

8. Assess patient’s vital signs and 8

characteristics of pain at least 30
minutes after administering the
medication.

R: To monitor the effectiveness of the

medication for the relief of flank and
lower abdominal pain. The time of
monitoring of vital signs may depend
on the peak time of the drug
administered.

9. Elevate the head of the bed and 9

position the patient in a Semi Fowler’s.
R: To increase the oxygen level by
allowing optimal lung expansion.

10. Elevate the side rails of the bed. 10

R: Elevating the side rails will prevent

the patient from risk of falling or injury.
Since the patient is in pain, most likely
the patient will be on bed rest. Severe
pain may cause discomfort to the
patient and the patient may be twisting
and turning in the bed.
REFERENCES:

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2012). Diagnoses, Prioritized Interventions, and Rationales. DavisPlus.

Gulanick, M., Myers, J., (2013, Mosby) Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8th edition.

Herdman, H., Kamitsuru, S., Lopez, C., (2021, Thieme). NANDA International, Inc. Nursing Diagnoses Definitions and Classification, 12th edition.

Maddukuri, G. (2022, August 22). Blood in Urine. MSD Manual Consumer Version. Retrieved September 18, 2022, from
https://www.msdmanuals.com/home/kidney-and-urinary-tract-disorders/symptoms-of-kidney-and-urinary-tract-disorders/urine-blood-in

Swearingen, P L., (2016, Mosby). All-in-One Nursing Care Planning, 4th edition