NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Sumasakit ung kanang balikat ko as verbalized by the client. Pain scale: 5/10 OBJECTIVE: -irritability -restlessness

Acute pain related to inflammation of musculoskeletal tissue as evidenced by irritability and restlessness. Inference: Acute pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage.

Short Term Goal: After 30 mins. To 1 hour of nursing intervention the client s pain will be reduced from pain scale of 5/10 to 3/10. Long Term Goal: After 1-2 days of nursing intervention the client s pain will be relieved.

Independent: >assess for referred pain as appropriate

 Goal met >to help determine possibility of underlying condition requiring treatment >to promote nonpharmacological pain management After 1 hour of nursing intervention client s pain was reduced from pain scale of 5/10 to 3/10.

>Provide comfort measures such as touching, repositioning an use of heat packs. >Provided rest periods

>To facilitate comfort, sleep and relaxation >to destruct attention and reduce tension

>Instruct/ encourage use of relaxation techniques such as breathing exercises

Dependent: >Administer analgesics as prescribed by the physician.

>to alleviate pain & meet pain control goal

Patients Name: N.S Dx : Adhesive Capsulitis R Shoulder

NURSING CARE PLAN