Nursing Care Plan

Name of the Patient :

Medical Diagnosis :
Nursing Diagnosis : Acute pain
Short-Term Goal : Within the shift, the patient’s pain will be decreased from 7/10 to 3/10.
Long-Term Goal : At the end of hospitalization, patient will not manifest any signs and symptoms of pain.

Scientific
Cues Problem Nursing Intervention Rationale Evaluation
Reason

Subjective: Acute Unpleasant ➢ place in semi- ➢ the position Goal met:

“masakit ang katawan Pain sensory and fowlers position, facilitates
ko”; as verbalized by emotional use pillow for relaxation of Patient’s pain
the patient. experience arising support the abdomen decreased from
from actual or muscles which 7/10 to 3/10.
potential tissue may help
Objective: damage or lessen
described in terms ➢ provides sensation of
➢ pain scale of of such damage analgesic as pain
7/10 prescribed
➢ facial grimace ➢ Pain
➢ disturbed body medications are
image typically
withheld or
given sparingly
so as not to
mark
symptoms,
which may help
pinpoint
diagnosis

Submitted by: Ray Francis C. Bravo