Nursing Care Plan

CUES NURSING DIAGNOSIS

ANALYSIS GOAL and OBJECTIVES

INTERVENTION RATIONALE EVALUATION

Objective:

BP 200/ 110 mmHgas of 10:35 am170/130 mmHg as of 10:55 am

Heart rate is irregular

Pale looking

Restlessness

Dizzy

Weaken

Nausea

Vomited twice

Grimace

Scattered movement

Acute pain related to severe headache as evidenced by high blood pressure, irregular heart rate, restlessness, nausea and vomiting, scattered movement and grimace

Acute Pain is unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage ( International Association for the Study of Pain); sudden or slow onset at any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months

( Nurse’s Pocket Guide 12th edition,

Goal :

After 1 hour and 10 minutes of nursing interventions the client will be able to verbalize or report pain is relieved or controlled.

Objectives:

1. After 5 minutes of discussion, the client will be able to verbalize what acute pain means.

2. After 15 minutes of

Supplemental:

1. Discuss what acute pain is.

2. Discuss effects

1. The meaning of the pain will directly influence the patient’s response. Some patients, especially the dying may feel that the “act of suffering” meets a spiritual need. (Nursing Diagnosis Care Plan, Chapter 14, pg. 146 by Gulanick Myers)2. To promote ways to maximize level of

EFFECTIVENESS

1. Was the client able to state the meaning of pain?Yes__ No__Why? ________

2. Was the client able

Reduced interaction with people and environment

pg. 586 by Doenges, Moorhouse and Murr. )

The Phenomenon of Pain

The gate control theory, which was proposed in 1965, gained wide acceptance and stimulated significant clinical research related to pain response and control. The theory suggest that the transmission of painful stimuli can be modulated through gating mechanism located in the substantia gelatinosa in the dorsal horn of the spinal

discussion the client will be able to enumerate the impact of pain on lifestyle.

3. After 10 minutes of discussion client will be able to enumerate the importance of having adequate rest periods.

4. After 10 minutes of discussion the client will be able to enumerate effects of alcohol or drug use in the response or choice of the analgesics for pain management.

5. After 5

of pain to lifestyle.

3. Discuss importance of adequate rest periods.

4. Discuss effects of alcohols and drug use to the choice and response of analgesics for pain management.

Developmental:

5. Ask the client about the pain

functioning. ( Nurse’s Pocket Guide 12th edition, pg. 590by Doenges, Moorhouse and Murr.)

3. To prevent fatigue. (Nurse’s Pocket Guide 12th edition, pg. 590 by Doenges, Moorhouse and Murr.)

4. Factors in client’s lifestyle can affect responses to analgesics or choice of interventions for pain management. ( Nurse’s Pocket Guide 12th edition, pg. 589 by Doenges, Moorhouse and Murr. )

5. Pain is subjective

to enumerate effects of pain on lifestyle?Yes__ No__Why? _________

3. Was the client able to state the importance of adequate rest periods?Yes__ No__Why? _______

4. Was the client able to enumerate effects of alcohol and drug use to the choice and response of analgesic for pain management?Yes__ No__Why? ________

5. Was the client able to describe the pain she

cord. It is thought that activity in the peripheral and central nervous system could affect the opening and closing of the gate. Studies related to specific pain modulatory systems have supplemented the theory’s description of pain transmission and enhanced understanding of the neural mechanisms underlying the variability of the pain experience. In addressing the variability of the experience, the patient’s perception of and reaction to pain must also be considered.

minutes the client will be able to describe the pain she feels.

6. After 15 minutes of discussion and demonstration the client will be able to demonstrate comfort measures for pain.

7. After 10 minutes of discussion and demonstration the client will be able to demonstrate relaxation techniques to relieve pain.

experience and response to pain.

6. Discuss and demonstrate different kinds of comfort measures.

7. Discuss and demonstrate different kinds of relaxation techniques.

experience and cannot be felt by others.( Nurse’s Pocket Guide 12th edition, pg. 588 by Doenges, Moorhouse and Murr.)

6. To promote nonpharmacological pain management.( Nurse’s Pocket Guide 12th edition, pg. 589 by Doenges, Moorhouse and Murr. )

7. To distract attention and reduce tension.( Nurse’s Pocket Guide 12th edition, pg. 589 by Doenges, Moorhouse and Murr. )

is experiencing?Yes__ No__Why? ________

6. Was the client able to demonstrate different kinds of comfort measures?Yes__ No__Why? ________

7. Was the client able to demonstrate different kinds of relaxation techniques?Yes__ No__Why? ________

( Cognitive – Perceptual Pattern, pg. 512 by McGraw – Hill Book Co. , Fields HL

EFFICIENCY

Were resources available to the nurse and client maximized?Yes__ No__Why? ________

APPROPRIATENESS

Were interventions appropriate to client with severe headache?Yes__ No__Why? ________

ACCEPTABILITY

Were all interventions acceptable to the client?Yes__ No__Why? ________

ADEQUACY

Were the numbers of interventions enough to solve the health problem?Yes__ No__Why? ________

FAR EASTERN UNIVERSITY

INSTITUTE OF NURSING

NURSING

CARE PLAN

Submitted by: Submitted to:

MAYLS S. CALIZO MRS JOANNE LOJO

BSN 301 CLINICAL INSTRUCTOR

Nursing Care Plan

CUES NURSING DIAGNOSIS

ANALYSIS GOAL and OBJECTIVES

INTERVENTIONS RATIONALE EVALUATION