NURSING CARE PLAN

PAIN

Assessment
Subjective :
Masaki tang aking
dibdib as verbalized
by the patient.
Objective :

Facial grimace
Restlessness
Positioning to
avoid pain.
Pain scale 7 /
10

Vital signs :
BP : 140/100 mmHg
RR : 23 cpm
PR: 110 bpm
T: 38.5 celcius

Diagnosis
Acute pain
related to
myocardial
ischemia as
evidenced by
Facial grimace,
Restlessness
,Positioning to
avoid pain and a
Pain scale 7 / 10

Planning
STG :

Intervention
Independent :

After 1 hour of
nursing
intervention the
client will able to
reduce pain from
7 to 3.

Monitored
vital sign.

Provided
comfort
measures
quite
environment
and calm.

Acute pain is an
unpleasant
sensory
And emotional
experience
arising from
actual or
potential tissue
damage. Sudden
or slow onset of
any intensity
from mild to
severe.

Upon discharge
of the patient ,
He will be able
to go back to his
ADL without due
pain and
discomfort.

Encouraged
adequate
rest.

Monitored
surgical for
dehiscence
and
evisceration.

To served as
base line
data.

To promote
nonpharmacologi
cal pain
management
.

To prevent
fatigue.

Careful
monitoring
enables early
detection.

To maintain
acceptable
level of pain.

Dependent :
Administered
Analgesics as
prescribed by the
physician.

Evaluation
Goal met.

LTG :
Inference:

Rationale

After an
effective
nursing
interventio
n the
patient
verbalized
a relief of
pain and
pain scale
was
reduced
from 7 to
3.

Collaborative :

Collaborate with
Cardiologist

Assessment

Diagnosis

Planning

Intervention

For the
treatment of
causes that
distribute to
pain.

Rationale

Evaluation

Subjective :
Nurse mainit ang
pakiramdam ko pa
punasan naman
ako wala yung
nagbabantay sa
akin eh as
verbalized by the
patient.

Hyperthermia
related to
infection as
evidenced by
Flushed skin,
Restlessnes ,Skin
warm to touch
and temperature
of 38.5 celcius

STG :
After 30 minutes
of effective
nursing
intervention the
patient s
temperature will
decreased from
38.5 to 37.5
celcius.

Independent :

Monitored
vital signs.

Provided
Tepid
sponged
bath.

Removed
excess
clothing
and covers.

Goal met

Objective :
LTG :

Flushed skin
Restlessness
Skin warm to
touch.
Weakness

Vital signs:
BP : 140/100
mmHg
RR : 23 cpm
PR: 110 bpm
T: 38.5 celcius
Laboratory:
Neutrophils :

Upon discharged
of the patient he
will be able to
maintain normal
body
temperature and
can perform his
activities of
daily living.

To served
as a
baseline
data.
To
decrease
body
temperatu
re of the
patient, &
to
Increase
heat loss
through
conductio
n.

To
decreases
warmth
and
increases
evaporativ
e cooling.

To meet
the
increase

Provide
adequate
of nutrition
and fluids.

The patients
body
temperature
decreased from
38.5 to 37.5
celcius.

 75.9 =
55 - 70 its normal
range

metabolic
demands
and
prevent
dehydratio
n.

Dependent :
Administer anti
pyretics as
ordered by the
physician.

Collaborative

To reduced
the
clients
fever.