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NURSING CARE PLAN: PAIN

Name of Patient: Montalban Rizal


Age: 45 years old
Diagnosis: Acute Pyelonephritis

NURSING ANALYSIS/HEALTH GOAL AND NURSING


CUES RATIONALE EVALUATION
DIAGNOSIS IMPLICATION OBJECTIVES INTERVENTIONS

INTERACTION Acute pain related IMMEDIATE CAUSE GOAL


“Masakit ung dito to acute Acute inflammation of After 8 hours of
(pertaining to the inflammation of renal tissues nursing
lower abdomen), renal tissues as INTERMEDIATE intervention, the
tapos pag manifested by CAUSE client will be able
gumagalaw ako patient’s Acute pyelonephritis to report
masakit din. verbalization, ROOT CAUSE relief/control of
Minsan sa likod, behavior, and Stone formation pain.
tapos dito sa baba changes in vital
ng dibdib.” signs HEALTH OBJECTIVES
- When asked to IMPLICATION 1) After 15-20 1) Perform physical Pain is a 1) Was the client
describe the Genitourinary pain is minutes of assessment which subjective able to be
intensity of pain on usually caused by physical includes location experience and assessed for
a scale of 1-10, the distension of some assessment, the and characteristics must be precipitating/
patient said its 6 portion of the urinary client will be of pain described by the contributing factors
tract because of assessed for client in order to of his pain after 15-
OBSERVATIONS obstructed urine flow precipitating/ plan effective 20 minutes of
patient’s facial or inflammation and contributing treatment. physical
expressions show swelling of tissues. factors of his Kozier, assessment?
signs of pain Severity of pain of pain. Fundamentals of Yes __ No __
- guarding pain is related to the Nursing, 7th ed., If No, Why?
behavior on the sudden onset rather p.1164
lower abdomen than the extent of
- patient looks distension. a. Use pain Provides baseline
restless and weak Unrelived acute pain assessment scale to for assessing
can affect the identify intensity of changes in pain
pulmonary, pain. level and
cardiovascular, evaluating
gastrointestinal, interventions.
endocrine, and Smeltzer & Bare,
immune systems. The Medical Surgical
NURSING ANALYSIS/HEALTH GOAL AND NURSING
CUES RATIONALE EVALUATION
DIAGNOSIS IMPLICATION OBJECTIVES INTERVENTIONS
MEASUREMENT stress response Nursing, 10th ed.,
Blood Pressure: (“neuroendocrine pp.245
150/90 up to response to stress”)
160/90 mmHg that occurs with b. Assess and Data assist in
Respiratory rate: trauma also occurs record pain and its evaluating pain
25 up to 28 with other causes of characteristics: and pain relief
breaths per min severe pain. The location, quality, and identifying
widespread endocrine, frequency and multiple sources
immunologic, and duration. and types of pain.
inflammatory changes Smeltzer & Bare,
that occur with stress Medical Surgical
can have significant Nursing, 10th ed.,
negative effects. This pp.245
is particularly harmful
in patients c. Note cultural and Each person
compromised by age, developmental experiences and
illness, or injury. influences affecting expresses pain in
Smeltzer & Bare, pain response. an individual
Medical Surgical manner using a
Nursing, 10th ed., variety of social
pp.218,1259 adaptation
techniques.
Kozier,
Fundamentals of
Nursing, 7th ed.,
p.1164

d. Monitor vital Usually altered in


signs. acute pain.
Doenges,
Moorhouse,
Geissler-Murr,
Nurse’s Pocket
Guide, 9th ed.,
p.367

2) After 10-15 Discuss with the Personal factors 2) Was the client
minutes of client the importance can influence able to verbalize
interaction, the of eliminating pain and pain reduction of
client will be able precipitating factors tolerance. Those precipitating
NURSING ANALYSIS/HEALTH GOAL AND NURSING
CUES RATIONALE EVALUATION
DIAGNOSIS IMPLICATION OBJECTIVES INTERVENTIONS
to verbalize such as fear, factors that may factors of pain after
reduction of fatigue, anxiety, and be precipitating or 10-15 minutes of
precipitating stress. augmenting pain interaction?
factors of pain. should be Yes __ No __
reduced or If No, Why?
eliminated to
enhance the
overall pain
management
program.
Fundamentals of
Nursing, 7th ed.,
p.1164

3) After 20-30 a. Teach patient the The use of non- 3) Was the client
minutes of use of non- invasive pain able to be provided
intervention, the pharmacologic relief measures with non-
client will be techniques such as can increase the pharmacologic
provided with relaxation, music release of measures to
non- therapy or endorphins and reduce pain after
pharmacologic distraction. enhance the 20-30 minutes of
measures to therapeutic intervention?
reduce pain. effects of pain Yes __ No __
relief If No, Why?
medications.
Fundamentals of
Nursing, 7th ed.,
p.1164

b. Encourage To prevent
adequate rest fatigue.
periods. Doenges,
Moorhouse,
Geissler-Murr,
Nurse’s Pocket
Guide, 9th ed.,
p.367

4) After 5 minutes Administer Analgesics are


of drug Diclofenac more effective if 4) Was the client
NURSING ANALYSIS/HEALTH GOAL AND NURSING
CUES RATIONALE EVALUATION
DIAGNOSIS IMPLICATION OBJECTIVES INTERVENTIONS
administration, (Voltaren) 50mg 1 administered able to be given
the client will be tab PRN for pain as early in pain analgesics as
given analgesics prescribed by the cycle. prescribed by the
as prescribed by physician. Simultaneous use physician after 5
the physician. of analgesics that minutes of drug
work on different administration?
portions of the Yes __ No __
nociceptive If No, Why?
system will
provide greater
pain relief with
fewer side
effects.
Smeltzer & Bare,
Medical Surgical
Nursing, 10th ed.,
pp.245

a. Evaluate the The analgesic


effectiveness of dose may not be
analgesic at regular adequate to raise
frequent intervals the client’s pain
after each threshold or may
administration. be causing
intolerable or
b. Instruct patient dangerous side
and family about effects or both.
potential side effects Fundamentals of
of analgesics and Nursing, 7th ed.,
their prevention and p.1164
management.

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