NURSING CARE PLAN

ASSESSMENT Subjective Cues NURSING DIAGNOSIS Chronic pain related to tissue injury as evidenced by: Restlessness Pallor Elevated pulse - Increased respirations - Facial Grimace - Pain scale of 9 out of 10 PLANNING Within 8 hours of medical and nursing intervention the pain that the patient felt will be lessen as evidenced by: - Change in Pulse rate and respiration rate into normal baseline data - Pain scale of 5 out of 10 INTERVENTION - Elicit behaviors that are conditioned to produce relaxation, such as deep breathing, yawning, abdominal breathing, or peaceful imaging. - Create a quiet, non-disruptive environment with dim lights and comfortable temperature when possible. - Individualize the content of the relaxation intervention (e.g., by asking for suggestions about how the patient enjoys or finds relaxing). - Provide patient safety (e.g by raising the side rails) - Provide optimal pain relief with prescribed analgesics. EVALUATION After 8 hours of medical and nursing intervention the goal was partially met. As evidenced by: - The client shows some discomfort - Pain scale of 7 out of 10 - PR- RR-

Objective Cues Restlessness Pallor Elevated pulse Increased respirations Facial Grimace Pain scale of 9 out of 10