Acute Pain Nursing Care Plan
A perfect nursing care plan provides Five basic elements that include nursing diagnosis, goals, interventions, rationales and evaluations
| Nursing Diagnosis (from NANDA) | Goal | Nursing Interventions | Rationale | Evaluation |
| 1) Acute pain
It is associated with injuries to the tissue that is secondary. The occurrence of the pain occurs after the intervention of surgery or an injury that is acute. It is also experienced through pain that has a rapid onset. According to Ackley & Ladwig (2014), acute pain represents a combination of experiences that are unpleasant and are related to the emotional, perceptual as well as the sensory responses. In addition, it is associated with the emotional, behavioral and autonomy. Therefore, Bulechek (2012) is of the opinion that acute pain occurs for a short and sudden duration. |
Control of pain. As evidenced by the employment of analgesics in the appropriate way. Moreover, it is seen in the ability of the farmer to tolerate the pain. | Pain management.
It is paramount to perform an assessment that is comprehensive on the pain to determine its location, duration, severity and factors precipitating the pain (Yoost & Crawford, 2015). It also comprises the frequency, characteristics, quality and intensity of the pain. Yoost & Crawford (2015) categorically state that is key to consider the influences of culture in the response to the pain. In addition, it is paramount for the elimination of the factors that increase the experience of the pain such as fatigue, and fear. |
The pain represents an experience that is subjective. Therefore, it requires description as per the client’s experience to effectively plan for a treatment. Different people experience as well as express pain in a different way, using sociological techniques of adaptation. Galura, Canale, & Ulrich (2011) suggests that pain experience as well as our ability to tolerate pain is affected by personal factors. As a result, it is important to reduce the factors augmenting the pain to facilitate the program for the management of the pain. | The patients describe as well as rates his pain. The patient should be able to express confidence in the efforts to control the pain.
With the various changes in positions, the patient expresses comfort (Carpenito, 2014). There should be expressing of comfort when there is dispositioning of the leg. There should be reduced movements to decrease fixation as well as extreme movements. There should be the employment of pharmacological, psychological as well as physical measures aimed at reducing discomfort (Ackley & Ladwig, 2014). |
| 2). Impaired physical mobility. It is evidenced by the use of a front-wheel walker. It is also associated with the integrity loss of the structures of the bone. | To reduce or limit the motion range. It is also to slow the movement. In addition, it limits the ability of fine as well as gross performance. | To determine the appropriate immobility diagnosis. It is important to note the vital situations of the fracture. In addition, it is key to determining the immobility’s intensity or degree in association with the scale that is suggested (Ackley & Ladwig, 2014). It is also important to evaluate the complications presence that can be associated with the immobility such as pneumonia.
Moreover, it is key to assisting the client to continually reposition themselves on a regular basis (Galura, Canale, & Ulrich, 2011). Also, there is a need to support the part of the body that is affected by the use of pillows. It is also vital to encourage the intake of fluids as well as nutritious foods. |
To identify the factors that are contributing to the pain as they affect the mobility of the patient. It is also to evaluate the functional mobility (Yoost & Crawford, 2015). In addition, it is to evaluate the complications presence.
To foster the level that is optimum for the functionality and the prevention of the complications. To maintain the function as well as the position and decrease the risk of getting pressured ulcers. It assists in the promotion of the wellbeing. It also aids in the maximization of the production of energy in the body (Carpenito, 2014). The nurse as well as the physiotherapist to educate the patient on the exercises to adapt related to the post opt. These are aimed at increasing mobility. The nurse will also educate the patient on the proper way to change the positions in bed to relieve the pressure on the hip. The nurse should be able to offer the patient with materials for reading about the hip surgery (Bulechek, 2012). |
After interaction between the patient and the nurse, the patient shows comprehension of the individual treatment as well as the safety measures (Bulechek, 2012).
There is maintenance as well as the increase of the strength and the functionality of the part that is affected. The patient participates in activities that are desired as well as ADLs. |
| 3). Risk of infection. As evidenced by the secondary wound to the fracture. | Maintain asepsis | Notes the risk factor for the infections occurrence
It is important to observe the infections, signs of the localized region. There is a need to stress the importance of hand hygiene by the various caregivers (Bulechek, 2012). There are also the recommendations of the body shower on a regular basis. There should be a change of the surgical as well as other wounds for dressings as required by the nurse. It should be changed as well as disposed of in the proper way. This should follow the proper way of disposing materials that are contaminated. It’s also important to review the nutritional requirements of the individual |
To evaluate the factors that contribute to the pain.
To evaluate the sites that are infected It assists as a defense for the associated infections in healthcare, thus acts as the first line of defense. It assists in the reduction of the colonization by bacteria (Ackley & Ladwig, 2014). To prevent the risk of infection. It assists in the promotion of the wellbeing of the patient. |
After interaction with the nurse, the patient should be able to identify the interventions in reducing the infection risk. It assists in allowing the wound to heal. The wound should be free of the drainage purulent.
It should be able to be febrile as is shown by the V/S that is normal. The patient should maintain their vital signs within the acceptable range. There should be exhibition of an incision that is well approximated that lacks signs of drainage. |
References
Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook : an evidence-based guide to planning care. Missouri: Maryland Heights.
Bulechek, G. M. (2012). Nursing interventions classification (NIC). London: Mosby.
Carpenito, L. J. (2014). Nursing care plans : transitional patient & family centered care. Philadelhia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Galura, n. H., Canale, S. W., & Ulrich, S. P. (2011). Ulrich & Canale’s nursing care planning guides : prioritization, delegation, and critical thinking. Missouri: Saunders/Elsevier.
Yoost, B. L., & Crawford, L. R. (2015). Fundamentals of Nursing : Active Learning for Collaborative Practice. Missouri: Mosby.
