XI.

NURSING CARE PLAN PRIORITY 3

ASSESSMENT DIAGNOSIS BACKGROUND OF PLANNING INTERVENTIO RATIONALE EVALUATION
DIAGNOSIS N
Risk Factors: Risk for Patient may STG: Independent:
1.mechanical peripheral experience after 3 hours of
compression: neurovascular phantom limb pain nursing 1.monitor vital 1.To 1.Must be
-wound dressing disfunction: soon after surgery intervention, signs, watching determine if toknow the
-elastic bandage phantom limb or 2-3 months after the patient wil: for changes in there is condition of
2.Orthpaedic pain related amputation. He may -demonstrate BP, cardiac bleeding in his surgical
Surgery: to amputation feel sensations that and participate rate, the site. site.
-amputatio of the 5th were present before in the behaviors respiratory rate
n of the 5th phalange of the amputation and activities to note skin pallor 2.To help 2.Must be
phalange of the the left hand. such as tingling, present/minimiz and presence determine able to assess
left hand. heat and cold, or e complications of confusion. possibility of for referred
heaviness followed and underlying pain.
by burning and disturbance in 2.Remove any condition.
cramping or sensation of the jewelries from
shooting pain, it amputated the affected 3.To know 3.Must be
may dissappear area. limb (wrist the pain able to used
spontaneously or watches, scale. pain rating
persist for many bracelets. scale.
years the nursing LTG:
care focuses on the after 1 week of 3.assess 4.To help to 4.Was be able
prevention of it's NI, the patient capillary return, prevent the to noted his
occurrence that will: skin color, pain. attitude
may cause -relate signs warmth of the toward pain
discomfort and and symptoms affected limb at and use of
alterations of the that require risk and pain
patients activities of medical compare with medication.
daily living since reevaluation. unaffected 5.To
risk factors are extremeties. determine 5.Must be
present that can the extent of able to
predispose th 4.inspect verbalize observed non-
patient to tissues around pain. verbal cues
experience the and pain
peripheral bandaged/supp behaviors.
 neurovascular ort edges fr
dysfunction. rough edges for
places,
pressure
points.

XI. NURSING CARE PLAN PRIORITY 1

ASSESSMENT DIAGNOSIS BACKGROUN PLANNING INTERVENTI RATIONALE EVALUATION
D OF ON
DIAGNOSIS
perform 6.To promote 6. Must be
neurovascular non noted when
assessment, pharmacologi pain occurs.
nothing cal pain
changes in management.
motor/sensory 7. Was able to
function. Ask 7.Usually encouraged
the client to altered in verbalization
localize acute pain. of feelings
pain/discomfo about pain.
rt and to
report 8.Must be
numbness 8.To promote able to
and tingling. comfortable provided
5. to the patient. comfort
measure.
9.To know the
abnormal 9.Was able to
findings. monitored
skin color,
temperature
and vital
10.To know signs.
the
 knowledge 10.Was able
and to ascertained
expectation client’s
about the knowledge
pain and
management. expectations
about pain
management.

1.To know the Dependent:

cause of pain.
1.Has checked
vital signs
after surgery,
has referred
to the

XI. NURSING CARE PLAN PRIORITY 1

ASSESSMENT DIAGNOSIS BACKGROUN PLANNING INTERVENTIO RATIONALE EVALUATION
D OF N
DIAGNOSIS
abnormal doctor.
findings.
2.assist the 2.Must be
2.Determine patient when able to assist
and document pain persists. the patient
presence of when pain
possible of persists.
patho-
physiological
and
psychological
cause of pain. 3.To assist the
neurological 3.Must be
 and able to assist
3.Assist in psychological the
thorough factors. neurological
evaluation and
including psychological
neurological 4.to maintain factors.
and acceptable
psychological level of pain. 4.Noted client
factors. locus of
5.For control.
4.Note client management
locus of of severe
control. persistent 5.For
pain. management
5.Note client of severe
attitude 6.TO prevent persistent
towards pain the pain. pain.
and use of pain
medication. 6.analgesics
7.To control has ordred.
6.Administer t6he pain.
analgesics as
ordered. 7.Has
demonstrated
7.Demonstrate the pain.
and monitor
use of self-
administration/
patient control
analgesics.

XI. NURSING CARE PLAN PRIORITY 1

ASSESSMENT DIAGNOSIS BACKGROUN PLANNING INTERVENTI RATIONALE EVALUATION
D OF ON
DIAGNOSIS
Collaborative:
1.Evaluate
and document
clients
response to
analgesia.

2.Treatment
of underlying
condition 1.Evaluate 1.Evaluated
causing pain and document and
and pro-active clients documented
management response to clients
of pain. analgesia. response to
analgesia.
3.Instruct 2.Treatment
client in use of underlying 2.Did
of condition treatment of
transcutaneou causing pain causing pain
s electrical and pro-active and pro-active
stimulation management management
unit, when of pain. of underlying
ordered. condition
3.Instruct
4.Identify client in use
signs and of 3.Instructed
symptoms transcutaneou client in use
and change in s electrical of
pain stimulation transcutaneou
characteristic unit, when s electrical
s requiring ordered. stimulation
medical unit, when
follow-up. 4.Identify ordered.
signs and
5.Provide for symptoms 4.Identified
individualized and change in signs and
physical pain symptoms
therapy or characteristic and change in
 exercise s requiring pain
medical characteristic
s requiring
medical
XI. NURSING CARE PLAN PRIORITY 1
ASSESSMENT DIAGNOSIS BACKGROUN PLANNING INTERVENTIO RATIONALE EVALUATION
D OF N
DIAGNOSIS
program that
can be
continued by
the client after
discharge.
1.To distruct 1.Was follow
Health attension and the instructed
teachings: reduce in and
1.Instruct in tension. encourage
and encourage use of
use of relaxation
relaxation techniques.
techniques. 2.To relax the
patient. 2.Must be
able to
encourage
2.Encourage 3.To prevent some
diversional fatigue. activities.
activities.
3.Was able to
4.To lessen do adequate
3.Encourage the pain. rest period.
adequate rest
period. 4. Has do the
5.To some
maximize therapeutic
4.Review some level of pain. techniques.
techniques
 such as 5.Was be able
therapeutic to discuss
technology. impact of
5.Discuss 6.To reduce pain on
impact of pain some factors lifestyle/
on that can independence
lifestyle/indepe cause pain. and ways to
ndence and maximize
ways to level of
maximize level functioning.
of functioning. 6.Must be
able to
6.Discuss with discuss some
SO(s) ways in ways to
which they can prevent the
assist client and pain.
reduce
precipitating
XI. NURSING CARE PLAN PRIORITY 1
ASSESSMENT DIAGNOSIS BACKGROUN PLANNING INTERVENTI RATIONALE EVALUATION
D OF ON
DIAGNOSIS
for pain STG:
control in the
past. factor After the 3-5
that may hours of
cause or nursing
increase pain. intervention
the patient m
able to
reported pain
is relieved
and prevent
LTG: infection
After 1-3 around the
months of Independent : 1.To prevent affected site.
 nursing infection. Independent:
intervention, 1.Do the
the patient surgical drain. 2.To know the 1.was be able
will be able to some to do the
demonstrate 2.Review methods that surgical drain.
use of client can prevent
relaxation previous the pain. 2. has review
skills and experiences the previous
diversion with pain and experience.
activities as methods
indicated for found either 3. To avoid
individual helpful of the pain.
situation. unhelpful
3. was be able
3.Identify to identified
ways of some ways to
avoiding or minimize the
minimizing pain.
pain.

XI. NURSING CARE PLAN PRIORITY 1

ASSESSMENT DIAGNOSIS BACKGROUN PLANNING INTERVENTI RATIONALE EVALUATION
D OF ON
DIAGNOSIS
Dependent:

1.Prescribe 1.To relieve 1Was be able

opoid the pain. to relieve
analgesics as some general
ordered. discomfort
 temporaly.

Collaborative:

1.Changing 1.Has change

the position the position of
using the patient.
distruction,
applying cool
wash clothes,
to face and
providing
back 1.To relax the
massage. patient. 1.Was be able
to encourage
Health the patient to
teachings 2.To exercise sit for a few
1.Encourage the patient. minute.
the patient to 2.was be able
sit for a few 3To prevent to ambulate.
minute. infection.
3. was able to
2.Encourage provide
the patient to proper
ambulate. environment
for wound
3.Septic healing.
wound
dressing.

XI. NURSING CARE PLAN PRIORITY 1

ASSESSMENT DIAGNOSIS BACKGROUN PLANNING INTERVENTI RATIONALE EVALUATION
D OF ON
DIAGNOSIS
4.Advise the 4.To maintain 4.Was be able
patient to eat immune to eat food
food reach in system. reach in
vitamin c. vitamin c.

5.Keep nails 5. To maintain 5.Must be

short. patient’s able to keep
hygiene nails short to
prevent
infection.

LTG:
After 1-3
months of
nursing
intervention,
the patient
must be able
to
demonstrated
use of
relaxation
skills and
diversion
activities as
indicated for
individual
situation.