NURSING CARE PLAN 1

NURSING CARE PLAN 1

1.      Acute pain related to surgical procedure as evidenced by patient’s pain score 6/10.

Goal: Patient’s pain score will be rating at 2 to 3 scale.

No.	Nursing Interventions	Rationales
1.	Assess pain characteristics such as: ·         Quality = sharp, burning, shooting. ·         Severity = 0-3 (mild pain).                4-7 (moderate pain).                8-10 (severe pain). ·         Location = anatomical descriptions. ·         Onset = gradual or sudden. ·         Duration = intermittent or continuous. ·         Precipitating factors.	Assessment of the pain experience is the first step in planning pain management strategies.
2.	Assess for the signs and symptoms associated with pain.	The patient in acute pain may have an elevated blood pressure, heart rate and temperature. The patient’s skin may be pale and cool to touch. The patient may be restless and have difficulty concentrating.
3.	Monitor patient’s response towards pain and pain management strategies.	Pain may be evaluated via effect of mood, emotion, restless and depression.
4.	Monitor the use of PCA in controlling the pain.	PCA is the IV infusion of an opiod through an infusion pump that is controlled by the patient. This allows the patient to manage pain relief within prescribed limits.
5.	Monitor possible PCA complications such as excessive sedation, respiratory distress, urinary retention, nausea and vomiting, constipation and IV site pain, redness and swelling.	Early assessment of complications is necessary to prevent serious adverse reactions to opiod analgesics.
6.	Provide complete rest in bed to facilitate comforts, sleep and relaxation.	The patient’s experienced of pain may become exaggerated as the result of fatigue.
7.	Encourage patient to use non pharmacological methods in managing the pain such as relaxation, music therapy and breathing exercise.	These techniques are used to bring about a state of physical and mental awareness and tranquility. The goal of these techniques is to reduce tension and subsequently reducing the pain.
8.	Administer appropriate pain relief method such as opiod analgesics (Ponstan, Cerebrex or Tramal) or local anesthetic agents as ordered by doctor.	Opiod may be administered orally, intravenously, systemically by PCA systems or epidural. Local anesthetic agents block pain transmission and pain in specific area. They are effective in managing mild to moderate pain.
9.	Instruct the patient to evaluate and report the effectiveness of measures used.	Pain relief strategies can be modified to promote more satisfactory comfort levels.
10.	Teach the patient about the purpose, benefits, techniques of use and action, need for IV line, other alternatives for pain control and need to notify the nurse of machine alarm and occurrence of untoward effects.	Effective pain management with PCA requires patient knowledge of how to use the equipment.

Evaluation : Patient was reports satisfactory pain control at a level less than 3 on a rating scale to 0 to 10.