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Vii. Nursing Care Plan Assessment Nursing Diagnosis Plan of Care Expected Outcome Evaluation Subjective: Independent: Short Term Goal

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The nursing care plan summarizes the plan for a patient experiencing acute pain related to a wound. The plan includes assessing the patient's pain level, vital signs, and behaviors; providing pain medication and oxygen as needed; keeping the patient resting in a semi-fowlers position; using relaxation techniques like deep breathing; and providing diversional activities. The expected short-term goal is to reduce the patient's pain level to a tolerable 3/10 within 30 minutes to 1 hour. The long-term goal is for the patient to be pain-free after 2 days of nursing interventions.

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Vii. Nursing Care Plan Assessment Nursing Diagnosis Plan of Care Expected Outcome Evaluation Subjective: Independent: Short Term Goal

Uploaded by

api-3828211
294 views1 page
The nursing care plan summarizes the plan for a patient experiencing acute pain related to a wound. The plan includes assessing the patient's pain level, vital signs, and behaviors; providing pain medication and oxygen as needed; keeping the patient resting in a semi-fowlers position; using relaxation techniques like deep breathing; and providing diversional activities. The expected short-term goal is to reduce the patient's pain level to a tolerable 3/10 within 30 minutes to 1 hour. The long-term goal is for the patient to be pain-free after 2 days of nursing interventions.

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Vii

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The nursing care plan summarizes the plan for a patient experiencing acute pain related to a wound. The plan includes assessing the patient's pain level, vital signs, and behaviors; providing pain medication and oxygen as needed; keeping the patient resting in a semi-fowlers position; using relaxation techniques like deep breathing; and providing diversional activities. The expected short-term goal is to reduce the patient's pain level to a tolerable 3/10 within 30 minutes to 1 hour. The long-term goal is for the patient to be pain-free after 2 days of nursing interventions.

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Attribution Non-Commercial (BY-NC)
Download as DOC, PDF, TXT or read online from Scribd
Download as doc, pdf, or txt
294 views1 page

Vii. Nursing Care Plan Assessment Nursing Diagnosis Plan of Care Expected Outcome Evaluation Subjective: Independent: Short Term Goal

Uploaded by

api-3828211
The nursing care plan summarizes the plan for a patient experiencing acute pain related to a wound. The plan includes assessing the patient's pain level, vital signs, and behaviors; providing pain medication and oxygen as needed; keeping the patient resting in a semi-fowlers position; using relaxation techniques like deep breathing; and providing diversional activities. The expected short-term goal is to reduce the patient's pain level to a tolerable 3/10 within 30 minutes to 1 hour. The long-term goal is for the patient to be pain-free after 2 days of nursing interventions.

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VII.

NURSING CARE PLAN

NURSING EXPECTED
ASSESSMENT PLAN OF CARE EVALUATION
DIAGNOSIS OUTCOME

Subjective: Alteration in Independent: Short Term Goal: Goals met:


comfort  Assess pain noting characteristics & After 30 mins -1 hour of  After 30 mins. of
The patient verbalized related to severity ( 0-10 scale) Investigate& report nursing intervention: nursing interventions
“Masakit ang sugat acute pain changes in pain as appropriate  Patient will report pain is patient pain was
ko.”  Assess vital signs noting tachycardia & at a tolerable level with a decreased from pain
increase in respiration pain scale of 3/10 scale of 6/10 to 3/10.
Pain Scale: 6/10  Continue encouragement for efforts & use  the patient will be able to  After 30 mins of
of relaxation techniques like deep perform relaxation nursing intervention
Objective: breathing exercises exercises such as: the patient was able to
 Assess degree of discomfort through • Proper positioning perform the ff.
Vital signs: verbal & non-verbal cues, note cultural • Deep breathing relaxation exercises:
T= 36.5°C influences on pain response • Proper positioning
exercises
PR= 94bpm • Deep breathing
 Provide accurate, honest information to • Adequate rest periods
RR= 22 cpm patient exercises
BP= 130/90
 Keep at rest in semi-fowlers position Long Term Goal: • Adequate rest
 facial grimace  Provide diversional activities like music After 2 days of nursing periods
 Speaks in slow intervention, the patient will
paced manner. Dependent: have comfort and will be
 Guarding relieved from pain as  The patient was totally
behavior  Administer analgesics as indicated evidenced by pain scale of relieved from pain and
0/10. had comfort
 Assist in oxygen inhalation as ordered

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