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Acute Pain Management Plan

The nursing care plan summarizes the assessment, nursing diagnosis, interventions, and evaluation for a patient experiencing post-surgical incision pain. The patient reported a pain level of 9/10. Nursing interventions included pain medication, monitoring vital signs, encouraging relaxation techniques, and ensuring a calm environment. After 4 hours, the patient no longer displayed pain behaviors and reported a mild pain level of 1-3, indicating the goal of pain control was met.

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issaiahnicolle
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359 views1 page

Acute Pain Management Plan

The nursing care plan summarizes the assessment, nursing diagnosis, interventions, and evaluation for a patient experiencing post-surgical incision pain. The patient reported a pain level of 9/10. Nursing interventions included pain medication, monitoring vital signs, encouraging relaxation techniques, and ensuring a calm environment. After 4 hours, the patient no longer displayed pain behaviors and reported a mild pain level of 1-3, indicating the goal of pain control was met.

Uploaded by

issaiahnicolle
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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NURSING CARE PLAN

PLANNING EVALUATION
NURSING GOAL / EXPECTED OUTCOME NURSING INTERVENTIONS
ASSESSMENT DIAGNOSIS

Subjective Pain, Acute; After 4 hours of nursing 1. Assessed reported or referred pain. After 4 hours of nursing
Sir “masakit ang ilalim ng related to intervention VR’s reported post- 2. Performed comprehensive assessment intervention, VR’s post-
labi ko” as verbalized by disruption of surgical incision pain will be of pain including location, surgical incision pain was
the patient. normal tissue controlled as evidenced by: onset/duration, frequency, quality and controlled as evidenced by:
integrity severity at 0-10 pain scale.
Pain scale reported at - Absence of antalgic behavior 3. Accepted clients description of pain. - Absence of antalgic behavior
9/10 - Absence of facial mask no sleep - Absence of facial mask and
4. Observed for non-verbal cues of pain.
disturbance no sleep disturbance
- Absence of expressive behaviors 5. Provided back-rub as non-
Objective - Absence of expressive
- with sub-labial post- - Displays no autonomic alteration pharmacologic measure for pain. behaviors
surgical incision wound in muscle tone 6. Monitored v/s. - Displays no autonomic
- guarded/protective - Absence of self-focusing behavior 7. Provided a calm and quiet environment. alteration in muscle tone
behavior - Pain scale reported rating at 1-3 8. Instructed to report pain as it occurs. - Absence of self-focusing
- with facial grimace categorized as mild pain 9. Instructed/encouraged deep breathing behavior
- restless and irritable exercises. - Pain scale reported at 1-3
- moaning to pain 10. Encouraged diversional activities such categorized as mild pain.
- flaccid as radio using a head set device.
- diaphoretic 11. Regulated Tramadol drip (300 mg Goal Met
- reduced interaction Tramadol + 234 cc PNSS) at 10 mcgtts/
minute as ordered.
VS taken as follows:
12. Administered Tramadol 25 mg IV for
RR: 28 breaths/ min
BP:160/110 mmhg breakthrough pain as ordered.
13. Continued to administer celcoxx 200mg,
1 cap BID post anesthesia order to lift
tramadol medication thru IV.

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