FAR EASTERN UNIVERSITY

INSTITUTE OF NURSING

NURSING CARE PLAN

GOAL AND NURSING

CUES DIAGNOSIS RATIONALE EVALUATION
OBJECTIVES INTERVENTION
S: Acute pain (right GOAL:
After ___ hour of
>The client leg) r/t to
nursing intervention,
verbalized that the inflammation the client will
experience reduction
pain on his right and swelling of
or alleviation of pain
leg makes him surrounding and discomfort.
experience sleep tissue as
OBJECTIVES:
disturbances. manifested by
After 1 hour of
nursing
O: intervention, the
client will be able
>Swollen right leg
to:
with presence of
1. Describe the
Ilizarov External
pain he is
fixator. experiencing and • Perform a  Pain is a EFFECTIVENESS
 his response to comprehensive subjective
the pain. assessment of experience and Was the client able to
>Pain upon
pain including must be identify negative factors
moving right leg location, described by in 2 minutes?
characteristics, the client in Yes? __ No? ___
(pain scale 5/10, 10
onset, duration, order to plan Why? _________
as the highest). frequency, effective
quality, intensity treatment.
or severity, and Client may not
>Poor capillary precipitating verbally report
factors of pain. pain and
refill within 6
Rate severity on discomfort
seconds of right a 0-10 scale. directly.
Note verbal and Comparing
lower extremity.
nonverbal cues, specific
such as characteristics
grimacing, of pain aids in
rigidity, and differentiating
guarding or postoperative
restricted pain from
movement. developing
2. Explore and complications.
perform the
methods for
alleviation or • Provide  Promotes Was the client able to
control of pain. information and problem state and explain the
anticipatory solving, helps causes of her present
guidance reduce pain condition in 1 minute?
regarding causes associated Yes? __ No? ___
of discomfort and with anxiety Why? _________
appropriate and fear of the
interventions. unknown. And
provides sense
 of control.

• Provide optimal  Each client

pain relief with has a right to
prescribed expect
analgesics. maximum pain
relief. Optimal
pain relief
using
analgesics
includes
determining
the preferred
route, drug,
dosage, and
frequency for
each
individual.
Medications
ordered on a
prn basis
should be
offered to the
client at the
interval when
the next dose
is available.

• Reposition client,  Relaxes

reduce noxious muscles, and
stimuli, and offer redirects
comfort attention away
measures. from painful
 sensations.
Promotes
comfort, and
reduces
unpleasant
distractions,
enhancing
3. Promote sense of well-
wellness. being.

• Encourage use of  The use of Was the client able to

breathing and noninvasive report willingness to
relaxation pain relief participate in the
techniques and measures can treatment process in 1
distraction. increase the minute?
release of Yes? __ No? ___
endorphins Why? _________
and enhance
the therapeutic
effects of pain
relief
medications.
• Encourage  Significant EFFIECIENCY
presence and others can play
participation of a therapeutic Were the resources
partner or role in post- available to the nurse
relatives as operative and client?
appropriate. client. Yes? __ No? ___
• Initiate deep-  Deep Why? _________
breathing breathing
exercises, enhances
incentive respiratory
spirometry, and effort. ADEQUACY
 coughing using Splinting
splinting reduces strain Were the numbers of
procedures, as and stretching interventions enough to
appropriate, 30 of incisional solve the client’s health
min after area and problem?
administration of lessens pain Yes? __ No? __
analgesics. and discomfort Why? ________
associated
with APPROPRIATENESS
movement of
abdominal Were the interventions
muscles. appropriate to the
Coughing is condition of the client?
indicated when Yes? __ No? __
secretions or Why? ________
• Evaluate the rhonchi are
effectiveness of auscultated. ACCEPTABILTY
the pain control  Research
measures used shows that the Were all interventions
through ongoing most common acceptable to the client?
assessment. reason for Yes? ___ No? ___
unrelieved Why? __________
pain is failure
to routinely
assess pain
and pain relief.
Many clients
silently
tolerate pain if
not
specifically
asked about it.
 • Encourage  To prevent
adequate rest fatigue.
periods

4. Verbalize • Encourage the

willingness client for follow  Premature
to comply up care and seek discontinuation
with the advices from the of treatment
suggested doctor if problem when client
follow up arises. At the begins to feel
care or if same time, well may result
adverse explain its in return of
effects purpose with infection and
arises. regards to his potentiate drug
condition. resistant strains.

SOURCE:
*(Kozier, et al.
(2007).
Fundamental of
Nursing, 8th
Edition,
Published by
Pearson
Education, Inc.,
Prentice Hall,
p.1224)
* Nurse’s Pocket
Guide p. 412)