NCP Acute Pain

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GENERAL SANTOS DOCTORS' MEDICAL SCHOOL FOUNDATION INC.

NCM RLE EXPOSURE


Area: Inclusive Date:

Patient's Name: Attending Physician: Student's Name:


Age and Sex: Diagnosis: Year and Section:
Chief Complaint: Group:

NURSING CARE PLAN


DIAGNOSIS and
ASSESSMENT OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION
INFERENCE
Subjective: Acute pain related to Within 1 hour of nursing Independent: Independent: After 1 hour of nursing
“medyo sakit na akoang inflammation as evidenced interventions, the patient will interventions goal met as
kamot maam” as verbalized by verbalization of pain be able to:  Assess degree and  Degree of pain is evidenced by:
by the patient “medyo sakit na akoang characteristics of directly related to
kamot maam”, with a pain General objectives: discomfort and pain. extent of circulatory General objectives:
promoted physical comfort.
Objective: scale of 5/10. To promote physical comfort. Note guarding of deficit, inflammatory
extremity. process, degree of Specific objectives:
 Facial Grimace Inference: Specific objectives: tissue ischemia, and
 Guarding behavior The International Association extent of edema Reported that pain or
for the Study of Pain Report that pain or associated with discomfort is alleviated and
VS taken as follows: (IASP) defined pain as “an discomfort is alleviated or thrombus controlled.
9/11/2023 6pm unpleasant sensory and controlled. development.
emotional experience Verbalize methods that Changes in Verbalized methods that
 Temp: 36°C associated with actual or provide relief. characteristics of pain provide relief.
potential tissue damage, or may indicate
described in terms of such Displayed a relaxed manner.
 BP: 120/20 mmHg Display relaxed manner; be development of
damage.” Another great and able to sleep or rest and complications
influential definition of pain engage in desired activity.
 PR: 67 BPM
is from Margo McCaffery,  Maintain bedrest (if  Reduces discomfort
a nurse expert on pain, who indicated) and may be suggested
 RR: 20 CPM
defined it as “pain is to prevent dislodging
whatever the person says it is of clot.
 O2sat: 96% and exists whenever the
person says it does.” The  Monitor vital signs,  To obtain baseline
unpleasant feeling of pain is noting elevated data
highly subjective in nature temperature.
that may be experienced by
the patient.
Acute pain is pain, as defined  Provide emotional  Refocuses attention,
above, that has a duration of support and promotes sense of
less than 3 months and relief encourage use of control, and may
can be anticipated or stress management enhance coping
predicted. The physiological techniques abilities in the
signs of acute pain emerge progressive management of the
from the body’s response to relaxation, deep stress of traumatic
pain as a stressor. Acute pain breathing exercises, injury and pain,
provides a protective purpose and visualization or which is likely to
to make the person informed guided imagery; persist for an
and knowledgeable about the provide therapeutic extended period.
presence of an injury or touch
illness. The unexpected onset
of acute pain reminds the Dependent:
patient to seek support,
assistance, and relief.  Administer  Relieves pain and
(Doenges, M. E., & medications, as decreases muscle
Murr, M. C. (2022). nursing indicated; for tension. Reduces
care plan: Guidelines for example, analgesics fever and
individualizing client care (opioid and non- inflammation.
across the life opioid) and
span (16th ed.). antipyretics, such as
acetaminophen
(Tylenol).

 Administer  Maintains circulating


intravenous (IV) volume to maximize
fluids or volume tissue perfusion.
expanders, as ordered
by the physician

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