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NURSING CARE PLAN

CUES NURSING ANALYSIS GOALS AND INTERVENTIONS RATIONALE EVALUATION


DIAGNOSIS OBJECTIVES
Subjective: Acute pain is the Goal: After 30 minutes
“Masakit yung state in which an After 30 minutes of nursing
sikmura ko na individual of nursing interventions,
paring experiences and intervention, the did the patient
nasusuka ako, reports the patient will be eliminate pain of
tapos minsan Acute presence of severe able to eliminate the esophagus
para akong discomfort or an pain of the and
hinaheartburn” Pain uncomfortable esophagus and regurgitation
as verbalized by Related sensation lasting regurgitation while
the patient. to Tissue from 1 second to while maintaining
Trauma less than 6 months. maintaining normal function
Objective: It is important to normal function of lower
-Pain scale of note that if a patient of lower esophageal
7/10 reports pain lasting esophageal sphincter and
-weak and pale longer than 6 sphincter and preservation of
in appearance months this is preservation of the esophageal
-burning considered chronic the esophageal tissue? Met:
sensation pain. tissue. unmet:
behind
breastbone Objectives: After 30 minutes
After 30 minutes of nursing
of nursing intervention, did
intervention, the the patient:
patient will:

-Describes Administer -Described


satisfactory pain medications as satisfactory of
control at a level ordered: pain control?
less than 3 to 4 -Proton pump - Reduce the Met:
on a rating inhibitors amount of acid Unmet:
scale of 0 to 10. produced in the
stomach
- Antacids - Are alkaline
substances that
counteract the
acid in the
stomach
- Antibiotic - Erythromycin
can help empty
the stomach

- Provide - Effectiveness
analgesics as of pain
ordered, medications
evaluating the must be
effectiveness and evaluated
inspecting for any individually
signs and because it is
symptoms of absorbed and
adverse effects. metabolized
differently by
patients.
Analgesics may
cause mild to
severe side
effects

- Hot or cold - Heat


compress decreases pain
through
improved blood
blow to the area
and through
reduction of
pain reflexes.
Cold lessens
pain,
inflammation,
and muscle
spasticity by
decreasing the
release of pain-
inducing
chemicals and
regulating the
conduction of
pain impulses.

-Demonstrates - Massage of the - A massage -Demonstrated


proper ways to affected area traps pain proper ways to
relieve pain when suitable transmission, relieve pain?
increases Met:
endorphin Unmet:
levels, and
minimizes tissue
edema. This
method requires
another person
to perform the
massage.

- Cognitive- - The aid of an


behavioral imagined event
strategies as or a mental
follows: picture involves
Imagery use of the five
Distraction senses to divert
techniques oneself from
Relaxation painful stimuli.
exercises, Increasing one’s
biofeedback, concentration,
breathing these
exercises, music techniques help
therapy an individual
decrease the
pain experience.
Breathing
modifications
and nerve
stimulations are
some of the
methods.

- Determine the - Patients with


appropriate pain acute pain
relief method. should be given
a non-opioid
analgesic
around-the-
clock unless
contraindicated.

-Patient - Foresee the - Preventing the -Patient


displays need for pain pain is one thing displayed
improvement in relief. that a patient improvement in
mood, coping. experiencing it mood coping?
can consider. Met:
Early unmet:
intervention may
decrease the
total amount of
analgesic
required.

-Get rid of - Patients may


additional experience an
stressors or exaggeration in
sources of pain or a
discomfort decreased
ability to tolerate
whenever painful stimuli if
possible. environmental,
intrapersonal, or
intrapsychic
factors are
further stressing
them.

- Remind the - Patient may


patient that pain give up trying to
is limited and that cope with pain
there are other when he or she
approaches to perceives pain
minimizing pain. as everlasting
and
unresolvable.