Nursing Diagnosis (NANDA)

1. Acute Pain related to postinfarction syndrome

Subjective Cues:
Sumasakit paminsan yung likod ko, as
verbalized by patient.
Objective Cues:
- Intermittent flank pain on right
- hypochondriac region of the
abdomen
- Pain scale of 5/10
- Diagnosed with Bladder and Renal
Carcinoma with Obstructive
Uropathy
- (+) facial grimace, irritable,
restlessness
Initial rating: 2
Scale for
Selected NOC
Outcome
Indicator
Reported pain

Facial expressions
of pain
Restlessness

Table No. 1 Nursing Care Plan

Nursing Outcome Classification
(NOC)
Chosen NOC:
Pain Level

Nursing Intervention
Classification (NIC)
Chosen NIC:
Pain Management

NOC Definition:
Amount of reported or demonstrated
pain.

NIC definition:
Alleviation of pain or reduction in
pain to a level of comfort that is
acceptable to the patient.

Objective of care:
At the end of 10-day nursing care,
the patient will be able to
demonstrate use of relaxation and
diversional techniques.

Target Outcome Rating:

Increase to: 4
Severe
Substantial
Moderate
1
2
3
Date/ Rating
3/2/1 3/3/1 3/4/1 3/5/1 3/6/1 3/7/1 3/8/1 3/9/1
4
4
4
4
4
4
4
4
1
1
2
3
3
3
4
4

Maintain At: 3
Slight
4
3/10/1
4
4

3/11/1
4
4

None
5
Evaluation

Reports minimal
experience of pain:
pain scale of 2/10
Absence of facial
grimace
Appears relaxed

and calm

Nursing Intervention Classification (NIC) Activity List

Nursing Diagnosis: Acute Pain related to post-infarction syndrome
Myra Levines Conservation Principle: Conservation of Energy; Conservation of Structural Integrity; Conservation of Personal
Integrity; Conservation of Social Integrity
Pain Management:
Rationale:
Perform a comprehensive assessment of pain to include
Pain is a subjective experience and must be described by
location, characteristics, onset, duration, frequency,
the patient in order to plan effective treatment.
quality, intensity or severity, and precipitating factors of
Personal factors can influence pain and pain tolerance.
pain. (Conservation of Structural Integrity)
Factors that may be precipitating or augmenting pain
Reduce or eliminate factors that precipitate or increase
should be reduced or eliminated to enhance the overall
clients experience (e.g., fear, fatigue, monotony, and lack
pain management program.
of knowledge). (Conservation of Energy and Personal
Integrity)
Research shows that the most common reason for
unrelieved pain is failure to routinely assess pain relief.
Evaluate the effectiveness of the pain control measures
Many clients silently tolerate if not specifically asked about
used through ongoing assessment of clients pain
it.
experience. (Conservation of Energy)
The client must feel comfortable trying a different
approach to pain management. To avoid ineffective
Consider clients willingness and ability to participate,
strategies, the client should be involved in the planning
preference, past experiences, and contraindications before
process.
selecting a specific relaxation strategy. (Conservation of
Personal Integrity)

Elicit behaviours that are conditioned to produce

relaxation, such as deep breathing, yawning, abdominal
breathing, or peaceful imaging. (Conservation of
Energy)

Relaxation techniques help reduce skeletal muscle tension,

which will reduce the intensity of pain.

Pain diminishes activity (Jacox et al, 1994; McCaffery,

Pasero, 1999).

Plan care activities around periods of greatest comfort

whenever possible.(Conservation of Energy)
Handle client's body gently. Allow client to move at own
speed. (Conservation of Structural and Personal
Integrity)
Demonstrate use of appropriate nonpharmacological
approaches for controlling pain, such as heat, cold,
distraction techniques, relaxation breathing, visualization,
rocking, stroking, music, and television. (Conservation of
Energy)
Create a quiet, nondisruptive environment with dim lights
and comfortable temperature when possible.
(Conservation of Energy)

Comfort and a quiet atmosphere promote a relaxed feeling

and permit the client to focus on the relaxation technique
rather than external distraction.