Care plan 1

Brooke Gagnon

NUR420

Maria Isorena

February 12, 2019

 Individualized Plan of Care- Nursing Process

Nursing Plan of Care

Assessment Clinical Problem Client goals/desired Nursing Intervention With Client Response
(subjective/objective) outcomes rationale
Prioritize clinical problem
Pain in left upper leg Ineffective pain Manage pain so that Administer ordered Pt rates pain as 0. Pt
Subjective: management due Pt rates pain as 0 and scheduled analgesics appears comfortable.
to recent spinal is comfortable before (Acetaminophen 1000mg
P- unsure surgery evidenced the end of my shift. PO QID).
Q- sharp by verbal pain
rating of 8/10,
R- to lower leg crying, and Rational: Control pain
appearing before it starts by giving
S- 8/10 uncomfortable and pain medication around the
T- started in the middle of restless. clock. (Lewis, 2019)
the night
U- unsure
Objective: Apply heat.

Pt was seen crying, Rational: applying heat

appeared uncomfortable, increases blood flow to the
and was restless. area which reduced the
activity of pain related
neurotransmitters. (Lewis,
2019)
Provide light massage.

Rational: providing a light

massage promotes
relaxation of muscles which
helps relieve pain. (Lewis,
2019)
References

Lewis, S., Bucher, L., Heitkemper, M., Harding, M., Barry, M., Lok, J., Tyerman, J., & Goldsworthy, S. (2019). Medical-surgical nursing
in Canada: Assessment and management of clinical problems (4th ed.). Toronto: Mosby Elsevier ISBN 9781771720489