Patient’s Name: X

Nursing Diagnosis: Acute pain r/t inflammatory response in affected vein as evidenced by reports of pain, tenderness.
Submitted by: Estoya, Gen Paulo C.
Reference: https://nurseslabs.com/
ASSESSMENT PLANNING/GOAL IMPLEMENTATION RATIONALE EVALUATION GOAL
Desired Outcome Independent/Dependent Reason for the Intervention Expected Outcome MET
Nursing Intervention
Pertinent Data: Patient will: Nurse will: Why: Positive result: Yes/No
Subjective:  Client will report  Assess degree and  Degree of pain depends on  Client reports that pain 
 Proxy report of that pain or characteristics of the extent of circulatory or discomfort is
pain discomfort is discomfort and pain. deficit, inflammatory alleviated or
activity/behavior alleviated or process, the degree of tissue controlled.
changes. controlled. ischemia, and extent of
 Reports intensity edema associated with
of pain.  Client will thrombus development.  Client verbalized
verbalize methods Changes in characteristics of methods that provide
Objective: that provide relief. pain may indicate the relief.
 Altered development of
physiological  Client will display complications.  Client demonstrates
parameter relaxed manner; relaxed manner; able
 Diaphoresis be able to sleep or  Investigate reports of  These signs and symptoms to sleep or rest engage
 Tenderness rest and engage in sudden or sharp chest suggest the presence of in desired activity.
 Restlessness desired activity. pain, accompanied by pulmonary embolism as a
dyspnea, tachycardia, complication of DVT or
and apprehension, or peripheral arterial occlusion
development of a new associated with heparin‐
pain with signs of induced thrombocytopenia
another site of vascular with thrombosis syndrome
involvement. (HITT). Both conditions
require immediate medical
treatment.

 Monitor vital signs,  Elevations in heart rate may

noting increased indicate increased discomfort
temperature. Maintain or may occur in response to
bed rest during the fever and inflammatory
 acute phase. process. Fever can also
increase client’s discomfort.

 Maintain bed rest  Decreases discomfort

during the acute phase. associated with muscle
contraction and movement.

 Encourage client to  Reduces muscle fatigue,

change position helps minimize muscle
frequently. spasm and maximizes
circulation to tissues.

 Provide foot cradle.  Cradle keeps the pressure of

bedclothes off the affected
leg, thereby reducing
pressure discomfort.

 Elevate affected  Encourages venous return to

extremity. facilitate circulation,
reducing stasis and edema
formation.

 Apply a warm  Moist heat may be applied to

compress to the
affected leg using a 2-
hour-on, 2-hour-off
schedule around the
clock.
the affected region to relieve
pain and improve circulation
through vasodilation.