LEADERSHIP AND MANAGEMENT

Student Nurse In –Charge: Student Head Nurse: LEOCHICO, Maricris M.

Patient: Mailo, Florencia Room and Bed No.: 505 Bed C

Nursing Care Plan:

Nursing Analysis Goal and Nursing Rationale Evaluation
Problem Objectives Intervention
Cues
Acute pain Scientific Analysis:
related to Pain is an unpleasant After 8 hours of EFFECTIVENESS:
multiple IV sensory experience nursing The nursing interventions
insertion trial arising from potential interventions, implemented are effective
tissue damage. It is a the client’s pain since the goal was met as
Subjective: subjective state in will be lessen as evidenced by the client’s
“Masaket naka 2 which a person evidenced by verbal report of decreased
tusok na sila.” demonstrates client’s pain from 7 to 3 on a pain
discomfort, verbally, statement of scale of 0-10, o indicating
“Wag ka lalapit, or non verbally, or decreased pain “no pain” and 10 as “worst
wag mo ng both. The pain from 10 to 5 on pain possible”.
gagalawin ung experience consists a pain scale of
bote, baka of two components: 0-10, o
pumutok perception and indicating “no EFFICIENCY:
nanaman, reaction. An intact pain” and 10 as The interventions done are
tutusukan nervous system is “worst pain efficient since they
nanaman ako ng required to perceive possible”. performed in the best
panibago” pain. Pain reaction is possible manner with least
what the individual Objectives: waste of time and effort;
Objective: feels, thinks and does After series of having and using requisite
about the perceived nursing knowledge, skill, industry
- guarding pain. An individual’s interventions, te and competency.
behavior response to pain is client will be INDEPENDENT:
- protective influenced by able to: a. Encourage a. Distraction ADEQUACY:
gestures emotions, level of diversional interferes with The interventions are
- irritability consciusness, cultural 1. be and calm pain stimulus by sufficient to achieve the
- 10/10 pain background, past provided with activities modifying goal.
scale (10 is experiences with pain pain such as awareness of
the most and meaning of pain. management newspaper pain. It is best
painful) Pain interferes with a interventions reading. used for periods APPROPRIATENESS:
person’s ability to . with mild to The interventions planned
rest, concentrate, and moderate pain. and carried out are
perform normal (Medical-Surgical appropriate to the
activities. Nursing Care Plans. identified problem. They
Engram, p.703) were also appropriate for
(Medical-surgical the client’s age and level
Nursing Care Plans, b. Reduce noise b. Usually, intense of understanding.
Engram p. 700) and bright environmental
lights. stimuli intensify
Health Implication: pain perception. ACCEPTABILITY:
Pain is a valuable (Medical-Surgical The interventions are
diagnosis indicator; it Nursing Care Plans. acceptable since they
usually indicates Engram, p.703) yielded positive results
tissue damage or and promoted client’s
pathology. Pain is c. Encourage c. Adequate rest wellness.
usually reported as periods of and sleep is
severe discomfort or rest. essential for the
an uncomfortable speeding up of
sensation. It poses a pain
threat to basic needs management
by: processes. Lack
of sleep and rest
• interfering with the can also be a
ability to meet food, cause of pain and
fluid and sleep can also increase
needs pain. Therefore,
• affecting elimination sleep and rest
• Interfering with are very
breathing and necessary in pain
meeting oxygen relief
needs. (www.buzzle.com)
• Limiting mobility,
leading to impaired
skin integrity and DEPENDENT:
altered ability for
self care. a. Review the
intervention a. To promote
s discussed wellness and
to lessen facilitate
the pain and continuous care
teach the in the absence
client and of health care
significant provider.
It also poses a threat others the (Nurse’s Pocket
to a higher level proper way Guide, 11th ed. By
needs by: to do it. Doenges p. 501)

• interfering with b. Review with

relationships with the client b. To promote
significant others, 2. promote the wellness and
communication, wellness activities facilitate
sexuality, social that she continuous care.
environment, and may or may (Nurse’s Pocket
job performance not do to Guide, 11th ed. By
prevent Doenges p. 501)
• causing spiritual aggravation
distress and of pain.
potentially leading c. Vitamin A plays
to violence. c. Advise an important
intake of role in immune
• Delaying nutritious system function
rehabilitation, and and helps resist
enabling Pin itself to balanced invasion by
become the foods microorganisms;
disability. appropriate Vitamin C has
for the antiviral activity,
(REF: Medical Surgical client’s age and may help
nursing 4th Ed. By and prevent viral
Hargroove-huttel. condition. infections, also
p.73) Stress the reduces the
importance severity and
of including duration of an
foods rich in infection.
Vitamin A
and C in her Nutrition is a
Low Fat Low major
Salt Diet. contributor to
the functioning
of the immune
system, which in
turn influences
whether or not
the body is
resistant to
infection.