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    NCP Head and Neck

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    Kristine Angie Ramos
    The document outlines a nursing care plan for a patient experiencing acute pain in their left ear. It includes an assessment noting the patient's subjective report of ear pain rated 8/10 and objective findings of irritability, elevated vital signs, and localized pain. Short term goals include the patient reporting decreased pain within 15-30 minutes. Long term goals are for the patient to report relief of pain within 2-3 days. Planned nursing interventions include assessment, positioning, applying a cold compress, encouraging rest and adequate hydration to reduce pain and prevent worsening of the patient's condition. The care plan was evaluated as successful, with goals fully met and the patient reporting decreased sensation and no recurrence of pain.

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    NCP Head and Neck

    Uploaded by

    Kristine Angie Ramos
    53 views2 pages
    The document outlines a nursing care plan for a patient experiencing acute pain in their left ear. It includes an assessment noting the patient's subjective report of ear pain rated 8/10 and objective findings of irritability, elevated vital signs, and localized pain. Short term goals include the patient reporting decreased pain within 15-30 minutes. Long term goals are for the patient to report relief of pain within 2-3 days. Planned nursing interventions include assessment, positioning, applying a cold compress, encouraging rest and adequate hydration to reduce pain and prevent worsening of the patient's condition. The care plan was evaluated as successful, with goals fully met and the patient reporting decreased sensation and no recurrence of pain.

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    ncp head and neck

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    The document outlines a nursing care plan for a patient experiencing acute pain in their left ear. It includes an assessment noting the patient's subjective report of ear pain rated 8/10 and objective findings of irritability, elevated vital signs, and localized pain. Short term goals include the patient reporting decreased pain within 15-30 minutes. Long term goals are for the patient to report relief of pain within 2-3 days. Planned nursing interventions include assessment, positioning, applying a cold compress, encouraging rest and adequate hydration to reduce pain and prevent worsening of the patient's condition. The care plan was evaluated as successful, with goals fully met and the patient reporting decreased sensation and no recurrence of pain.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    53 views2 pages

    NCP Head and Neck

    Uploaded by

    Kristine Angie Ramos
    The document outlines a nursing care plan for a patient experiencing acute pain in their left ear. It includes an assessment noting the patient's subjective report of ear pain rated 8/10 and objective findings of irritability, elevated vital signs, and localized pain. Short term goals include the patient reporting decreased pain within 15-30 minutes. Long term goals are for the patient to report relief of pain within 2-3 days. Planned nursing interventions include assessment, positioning, applying a cold compress, encouraging rest and adequate hydration to reduce pain and prevent worsening of the patient's condition. The care plan was evaluated as successful, with goals fully met and the patient reporting decreased sensation and no recurrence of pain.

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    St.

    Paul College of Ilocos Sur


    (Member, St. Paul University System)
    St. Paul Avenue 2727, Bantay, Ilocos Sur

    DEPARTMENT OF NURSING
    BACHELOR OF SCIENCE MAJOR IN NURSING

    Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

    Subjective: Acute pain Short Term (Independent) After the nursing


    “ Sumasakit ang kaliwang - Within 15-30 mins of - Perform assessment to - To identify and rule out intervention, goals are fully
    tenga ko.” as verbalized nursing intervention evaluate characteristic worsening of met. The client was able to
    by the patient. the patient will be able of pain. underlying condition or report decrease sensation and
    to report decreased of development of non-recurrence of pain as
    pain. complications evidenced by the patient.
    Objective Data: Long Term - Monitor vital signs - To monitor patient’s
    - Irritable - Within 2-3 days of health status
    - Pain rated as 8 out of nursing intervention - Position the patient in - To promote non-
    10 the client will be able a relaxed position. pharmacological pain
    - Vital Sign to verbalize relieve of - Advice breathing management and
    pain. technique, massage, reduce tension
     Temp: 37.2 imagery.
     PR: 120
     RR: 20 - Apply cold compress - it has an numbing
    on head and neck effect that may dull the
    - Encourage adequate sensation of pain.
    rest periods. Follow - To prevent fatigue that
    regular sleep scheduler can lead to headache
    and encourage to

    RAMOSKRISTINEANGIE@GMAIL.COM 1
    avoid exposure to
    radiation

    - Increase fluid intake


    - Being hydrated can
    prevent migraine
    attack

    RAMOSKRISTINEANGIE@GMAIL.COM 2

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