Our Lady of Guadalupe Colleges

COLLEGE OF NURSING
Mandaluyong City
NURSING CARE PLAN
NAME OF PATIENT: RPJ
CASE: Viral Encephalitis
Assessment
Diagnosis
S:
Acute Pain
- Masakit
r/t increased
po ulo
ICP
niya.
Nagrerekla
mo siya
noon.
Kaya,
irritable
siya
ngayon.
O:
- (+) facial
grimace
- Highly
irritable
- Crying,
restless

Inference
Viral invasion of
brain tissue

Brain tissue
damage

Planning
Goal: After 1 hour
of interventions,
the client will
report pain relieved
or controlled.
Objectives: At the
end of the
interventions, the
client will be able
to:

Intervention
The student nurse will:

Rationale

1. Perform a
1.
Increased ICP
comprehensive
assessment of pain

1. Recognize pain
(location,
onset and causal
characteristics,
Release of
factors
onset/duration,
chemical for local
frequency, quality,
effects (histamine,
intensity or severity of
kinins,
pain, and precipitating
prostaglandins,
factors)
leukotrienes)
2. Observe for nonverbal 2.
within localized
cues of discomfort
area of injury.

Provides
baseline data
and
information
about need
for, and
effectiveness
of
intervention.

Observations
may or may
not be

Evaluation
After one hour of
interventions, the client
was able to:

1. Standard: Recognize
pain onset and
describe causal
factors associated
with her pain
C:
[ ] Identify pain onset
and causal factors
2. Standard:
Demonstrate no nonverbal cues of
discomfort
Cues:
[ ] (-) facial grimace


These
neurotransmitters
that are released
stimulate the
nociceptors (free
nerve endings
found in skin,
muscle, bone,
joints, and
viscera).

Nociceptors alert
the brain to the
intensity of the
pain by increasing 2. Use preventive
the frequency of
measures
signals sent to
specialized areas
in the CNS

congruent with
verbal reports
or may be only
indicator
present when
client is unable
to verbalize.
3.

3. Assess and monitor

vital signs, noting
tachycardia,
3. Changes in
hypertension, and
these vital
increased respiration,
signs often
even if client denies
indicate acute
pain
pain and
discomfort

4. Promote change to a
position of comfort,
4. Repositioning
preferably maintained
may relieve
to a semi-Fowlers
pain and
position
enhance
circulation.

Signals travel
through spinal 3. Use non-analgesic 5. Provide backrubs for
cord into the area
relief measures
patient.
called the dorsal
horn.

[ ] (-) guarding
behavior
[ ] (-) expressive
vehavior
[ ] (-) diaphoresis
Standard: Maintain
stable and normal
vital signs
Cues:
[ ] BP: 90-120/60-80
[ ] T: 36.5 37.5 (Ax)
[ ] PR: 60-80 BPM,
regular, equal,
nonbounding
[ ] RR: 14-20 RPM,
effortless, eupneic

4. S: Demonstrate no
feeling of pain or
discomfort at rest
C:
[ ] (-) facial grimace
[ ] (-) guarding
behavior
[ ] (-) expressive
vehavior
[ ] (-) diaphoresis

5. Improves
5. S: Demonstrate less
circulation,
feeling of pain
reduces
C:
muscle tension
[ ] Verbalize feeling of


Pain signals are
sent up A-delta
nociceptor and Cnociceptor fibers
in the ascending
pathways to the
brain

Pain is interpreted
and consciously
experienced

6. Encourage diversional
activities

4. Use diuretics to
decrease ICP.

7. Administer mannitol
33mL q12h

and anxiety
associated
with pain.
Enhances wellbeing.
6. This will
distract
attention and
reduce
tension.

7. Mannitol is a
diuretic used
to decrease
the ICP.
Decreasing the
ICp prevents
headache

less pain and

discomfort

6. S: Demonstrate less
feeling of pain
C:
[ ] Less irritability
7. S: Utilize diuretics as
ordered.