Acute Pain NCCCCPPP GGGGG

SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
DUMAGUETE CITY
2nd Semester, Academic Year 2022
COLLEGE OF NURSING
IN PARTIAL FULFILLMENT OF THE REQUIREMENT IN
NCM 107 (RELATED LEARNING EXPERIENCE)
SUBMITTED TO:
Mrs. Sharry Mae G. Awayan, RN, MAN
SUBMITTED BY:
Coronado, Michelle, Solamillo, Janice
De los Santos, Steven Roy, Medalle, Cherilyn
Empeso, Michelle, Mancao, Joanamarica
DATE:
May 30, 2022
NURSING CARE PLAN FORM

COLLEGE OF NURSING
DUMAGUETE CITY
Patient’s Name (Initials): R. G Admitting Diagnosis/Medical Diagnosis/CC: Fracture Open 3A complete comminuted
intercondylar femur R
Age: 39 yrs old Physician (Initials): Dr.C.M.S
Sex: M Diet: Diet as tolerated
SUBJECTIVE OBJECTIVE NURSING SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EXPECTED
DIAGNOSIS ANALYSIS OUTCOME
Sakit jod siya

maam labi na  Facial Acute pain Acute pain Short Term: Independent:
katong bag o grimace related to usually
pa nahuman ang is seen disruption occurs That after 8 1. Monitor vital 1. To maintain After 8
opera. whenever of skin, immediately hours of signs every 4 baseline hours of
Ngulngol kaayo he feel tissue, nursing hours, and monitor nursing
after the
sa paminaw, pain. femur and intervention including the intervention
labi na ning inflammation fracture patient’s
 Irritabl the patient systolic and the patient
dapit sa e and as evidence when the condition
gibutangan og by facial bone has will be able diastolic which might shall have:
don’t
kaning metal. want to grimace and broken. The to: blood relate to
Magsigi gani talk. irritabilty pressure, pain felt  Report
pain felt
nakog  Change  Report pulse, by the decrease
by the
pabutangan og of pain is respitaory patient. of pain
Definition: patient is
ice kay murag position lessens and O2 in the
mo ayo-ayo man Unpleasant because of
either or saturation affected
gamay. Karon supine sensory and the cutting
controlle area
ang sakit ani or and of tissues
emotional d 2. Assess
mo tukar tukaw sitting. and nerves 2. To to allow
communicati 
experience patient pain Drink
jod japon” as  Inflamma during
verbalized by associated  Drink including on among pain
tion on operation,
the patient. right with actual medicatio the location, clinicians relief
or potencial which
leg. n at characteristi about the medicatio
COLLEGE OF NURSING
DUMAGUETE CITY
 Pain tissue current

scale: damage, or activate right cs, onset, status of n at
first visit described in the body's time. duration, the right
8-9/10 terms of automatic frequency, patient's time.
second 6/10 such injury Long Term: quality, and pain and
third 4/10 damage;sudde That after 3 responses Long Term:
responses severity of
n or slow days of to the plan That after 3
onset of any such as pain and pain of care.
 Medicati nursing days of
on for intensity inflammatio scale.
intervention nursing
pain and from mild to n. , the intervention
inflamma severe and patient will 3. Assess 3. Clients , the
tion: with a be able to : client’s perceptions patient will
duration of perception of nd be able to :
Paracetamol less than 3  Demonstra expression able
pain, along
(tempra) months. te use of of pain are
with influenced  experienc
relaxatio
Keterolac behaviors and by age,
n skills e pain
(ketopain) Reference: that cultural development
al stage, relief
relief expectations
Tramadol undelying from
Post- pain. regarding
(fucolac) Reference: surgery condition nonpharma
 Verbalize pain.
pain: d causing cologic
Celecoxib Doenges, M. Causes, medicatio pain,
(Saphecox) E., symptoms, ns that cognitive  Know what
Moorhous and help ease and are
e, M. treatments. pain. behavioral medicatio
F., & DevTCPC20.  Verbalize and
ns taken
Murr, A. (2022, d sense sociocultur
C. al factors. to relive
December of
(2019). 21). pain.
control
Nurse's Retrieved of
COLLEGE OF NURSING
DUMAGUETE CITY
response 4. This may

pocket January 8, to acute include ,  Know what
guide: 2023, from situation 4. Teach patient meditation, actions
Diagnose https://twi . nonpharmacolo deep should do
s, ncitiespain gic methods breathing inorder
prioriti clinic.com/ exercisesan
that lessens to
zed conditions/ d putting
interven post- pain with the ice on pain relieve
tions, surgery- significance location pain
and pain/#:~:te others. which help
rational xt=What decrease
es. F.A. %20causes pain.Signif
Davis. %20post icant
%2Dsurgery others
%20pain,inj provide
ury assistance.
%20response EVALUATION
s%20such 5. This will
%20as demonstrate  Patient
%20inflamma 5. Evaluate the improvement do cold
tion. patient’s status or compress
response to to identify and
worsening proper
pain and
of positioni
management ng when
underlying
strategies. condition he feel
Make sure to or pain.
document each developing  Drink
changes and condition. medicatio
compare from n in
right
COLLEGE OF NURSING
DUMAGUETE CITY
times
previous 6. Your broken  Patient
data. bone was usually
put into sleep
position when he
feel
and
6. Explain to pain.
stabilized.  Know what
the patient
You can medicatio
the possible
expect n he
cause of
some pain a drinks
pain.
nd swelling within
around the the day.
cut. It
will make
them less
worried.
7. Following
Dependent: this makes
7. Provide pain
pharmacologic relieve.
pain
management as
ordered.
COLLEGE OF NURSING
DUMAGUETE CITY
Collaborative
8. Foods like
8. Collaborate calcium,
to vitamin D
nutritionist and protein
about the help in
foods that faster
should be healing
taken to which means
faster faster
recovery of relieve of
bones. pain.
COLLEGE OF NURSING
DUMAGUETE CITY
COLLEGE OF NURSING
DUMAGUETE CITY
Patient’s Name (Initials): R. M. Admitting Diagnosis/Medical Diagnosis/CC: Abnormal Uterine Bleeding – Anemia 2°
Age: 28 yrs old Physician (Initials): Dr. N.A.C
Sex: F Diet: Diet as tolerated
COLLEGE OF NURSING
DUMAGUETE CITY
SUBJECTIVE OBJECTIVE NURSING SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EXPECTED

“Atong gi ● Pallor Risk of Fatigue is a That after 24

regla ko kas- Fatigue common Short Term: Independent: hours of
a maam, kay Laboratory related to presenting nursing
nakasulay gd results are decreased complaint in After 24 1. Monitor 1. To monitor intervention,
ko nga as follows: hemoglobin primary care hours of vital signs the baseline the patient
nakuyapan” as ● Hematocrit that has an providing the data and to shall have:
verbalized by decreased adverse effect nursing care, identify the - Attain a
the client Definition: on work complications relaxed
● Hemoglobin the patient
Fatigue is a performance, 1. Access appearan
decreased will be able ce
medical phrase home life, and the
to: 2. To relaxed
that describes social specific
Vital signs establis
taken as a lack of interactions. - Appear cause of h a - Identifi
follows energy and a Lifestyle fatigue
moderate baseline ed the
(5/27/22) general difficulties, and ask for basis of
ly relax
7-3 am: feeling of physical the activity fatigue
- Identify
BP: 110/80 exhaustion. diseases, levels,
basis of patient’s
Temp:35.7 It's more than mental fatigabi
fatigue fatigue
RR:89 just a drowsy disorders, and lity,
or sleepy drug adverse
using the
PR:65 and
feeling. effects are fatigue mental
3-11 pm: Fatigue can all included scale health
BP: 120/80 reduce a in the Long Term: in
Temp:36.4 person's differential relation
RR:24 After 3 days to
motivation to diagnosis of
PR:89 engage in fatigue. of fatigue
activities, Fatigue can be providing and
nursing 2. Teach exercise That after 3-
making them classed as
COLLEGE OF NURSING
DUMAGUETE CITY
more physiologic, intolera 4 days of

susceptible to chronic, or care, the deep nce nursing
a sedentary related to patient breathing intervention,
lifestyle. various will be technique the patient
Poor dietary medical able to: s shall have:
choices, lack disorders.
of exercise, - normal - Achieve
overexertion, 1. To allow normal
blood
the blood
substance References: pressure 3. Encourage
patient pressure,
addiction, Ream, E., - stable gradual stable
& to relax
emotional hematocri activity hematocri
Richardson, while
stress, or t and through t and
A. (1999, taking a hemoglobi
medical issues hemoglobi
March 23). self-care rest n levels
can all n levels
Fatigue: A and - Achieved
contribute to - desired
concept exercise. desired
it. ranges 2. To
analysis. ranges
International for progress
for
Journal of coagulati ively
coagulati
Nursing on 4. Review raise
the on
Studies. profiles. the
patient' profiles.
Retrieved May patient’s
31, 2022, s
lab physical
from
https://www.s values activity
ciencedirect. toleranc
com/science/a e
rticle/abs/pi
i/00207489960
00041 3. Fatigue
can be
COLLEGE OF NURSING
DUMAGUETE CITY
caused
by
anemia,
low
blood
Dependent sugar,
: and
5. Monitor other
hemoglobi physiolo
gical
n,
abnormal
hematocri ities
t,RBC caused
counts,an by
d underlyi
reticuloc ng
yte disease.
counts
4. To
establis
h the
patient’
Collaborative: s blood
profile
and
6. Collabora identify
te with deviatio
COLLEGE OF NURSING
DUMAGUETE CITY
ns from
the the norm
attending in order
physician to
about detect
changes
optimizin
in the
g patient'
medicatio s
ns conditio
n
5. Sleep
drugs,
sedative
s, pain
reliever
s, and
other
medicati
ons can
all
contribu
te to
wearines
s.
Changes
in
COLLEGE OF NURSING
DUMAGUETE CITY
frequenc
y and
dose
could
help
with
fatigue
complain
ts.
Patient’s Name (Initials): R. M. Admitting Diagnosis/Medical Diagnosis/CC: AUB – Anemia °

Age: 28 yrs old Physician (Initials): Dr. N.A.C
Sex: F Diet: Diet as tolerated
COLLEGE OF NURSING
DUMAGUETE CITY
SUBJECTIVE OBJECTIVE NURSING SCIENTIFIC PLANNING INTERVENTIONS 1. RATIONALE EXPECTED

The Tachycardia Fever due to Hyperthermia -

patient Lethargic blood is the Short Term: Independent: 1. To identify After 2-3
vebalized: Warm to touch transfusion elevation of abnormalitie hours of
“Galabad were observed tissue After 2-3 1. Monitor s and be
evidenced by nursing
imong ulo temperature able to
hyperthermia hours of Vital signs interventio
above normal
mam? May 30, 2022 nursing especially the compare
physiologic n Pt will
Gitugnaw BT was levels. Thus intervention temperature baseline
ka? transfused vital signs now be
Definition: the term Pt will be
@8:45 and was hyperthermia
able:
Core body relieve from
“Slight removed at encompasses a 2. This would - To be
temperature complication
lang”verba 1:00pm wide range of potentiate relieve
above the 2. Monitor and
lized by Vital signs: temperatures s and reduce fluid and d from
normal diurnal and modalities record all complic
the T:37 C the pt’s electrolyte
range due to sources of fluid ations.
patient P:112 temperature losses and
R:21 failure of Reference: loss is an - To
thermoregulatio “Hyperthermia - reduce
“Gakurog BP: 130/90 Long Term: essential
n. an Overview |
kurog man data when and
ScienceDirect After 1-2
to siya Topics.” the patient maintai
days of
ganina” as Www.sciencedire has a fever n
Nursing
verbalized Reference: ct.com, tempera
intervention
by the SO Nurses Pocket www.sciencedire ture.
, patients
Guide. Nurse S ct.com/topics/a 3. This would
core
Pocket Guide gricultural- 3. Apply cold provide Evaluation
and-biological-
temperature
15th Edition will compress on the comfort and
sciences/ After
Doenges maintain head relieves
hyperthermia. administerin
Moorhouse And within the pain as well
Murr Nanda as cooling g
normal range
Philipes Nurses down a fever Paracetamol
COLLEGE OF NURSING
DUMAGUETE CITY
Pocket Guide 4. This @2:10pm,

15th Edition indicates if patient’s
the fever temperature
4. Monitor came from an went from
laboratory tests underlying 39.5 C (from
cause 2:00 pm
assessment)
Dependent: to 37.7 C.
Dependent: 5.
5. This is to Patient’s
5. Administer reduce the general
antipyretics temperature appearance
much faster is not
Collaborative lethargic
Collaborative anymore as
6. Administer 6. To support well as no
circulatin signs of
replacement
g volume chills
fluids and and tissue observed
electrolytes perfusion.

Acute Pain NCCCCPPP GGGGG

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SAINT PAUL UNIVERSITY DUMAGUETE

SAINT PAUL UNIVERSITY DUMAGUETE

IN PARTIAL FULFILLMENT OF THE REQUIREMENT IN

NCM 107 (RELATED LEARNING EXPERIENCE)

Mrs. Sharry Mae G. Awayan, RN, MAN

Coronado, Michelle, Solamillo, Janice

De los Santos, Steven Roy, Medalle, Cherilyn

Empeso, Michelle, Mancao, Joanamarica

May 30, 2022

NURSING CARE PLAN FORM

Sakit jod siya

 Pain tissue current

response 4. This may

NURSING CARE PLAN FORM

SUBJECTIVE OBJECTIVE NURSING SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EXPECTED

“Atong gi ● Pallor Risk of Fatigue is a That after 24

more physiologic, intolera 4 days of

NURSING CARE PLAN FORM

Patient’s Name (Initials): R. M. Admitting Diagnosis/Medical Diagnosis/CC: AUB – Anemia °

SUBJECTIVE OBJECTIVE NURSING SCIENTIFIC PLANNING INTERVENTIONS 1. RATIONALE EXPECTED

The Tachycardia Fever due to Hyperthermia -

Pocket Guide 4. This @2:10pm,

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