The nursing care plan for pain. Pain is an unpleasant sensory experience due to tissue injury. Everyone has experience the pain in his/her life. Here are how you can make best Nursing Care plan with evidence based for acute pain.
Acute pain is, that if pain arise not more than 6 month of history. If pain duration is more than 6 month than it is fall under the chronic pain.
Nursing care plan is the systematic planning to deliver nursing care. And for both type pain i.e, acute and chronic pain, has different aspects of nursing care and nursing diagnosis here will be discussed about nursing care plan on acute pain. You can also check out nursing care for pyrexia.
Here Are The List of Nursing Diagnosis for Pain. This is All NANDA Approved Nursing Diagnosis for Pain.
- Acute pain related to inflammatory response of body cells to disease conditions as evidence by tachycardia, pyrexia and facial expressions and expressive behaviour.
- Alteration in comfort related to uneasiness due to pain arising from medical problems or superficial injury as evidence by tissue swelling and inflammatory sign.
- Risk for fluid Volume deficient related to dehydration due to pain and hyperthermia as evidence by skin turgidity and dryness of oral mucosa.
- Risk for injury related to uneasiness and discomfort as evidence by hyperkinetic, restlessness behaviour due to acute pain.
- Impaired comfort related to acute pain
- Impaired physical mobility related to restriction of mobilization due to pain.
- Impaired walking related to immobiliser plaster dressing to fractured tibia bone for pain.
- Impaired wheelchair mobility.
- Impaired bed mobility.
Here are the Nursing Care Plan for Acute Pain.
- Assessment :- By assessment following data or informations are collected; #Subjective Data – in which all information is recorded that are patients is complaining. #Objective Data – in which all observational information and data is Gatherd through nursing observation by some nursing skills or nursing techniques/procedure of health assessment.
- Nursing Diagnosis :- Based on data collected via nursing assessment an evidence based explainatory statement of problem is made as a form of nursing diagnosis.
- Interventions/Planning :- According to nursing diagnosis patients priorities and needs are find out and plan for treat that problems.
- Goal :- according to planing a nursing goal or objective is set.
- Implementation :- according to planning nursing care and nursing procedure is implemented.
- Rationale :- this explains the reason or scientific evidence to choose such kind of nursing services and procedures.
- Evaluation :- this steps is to evaluate whether the patient problems is treated or not. Means nursing goal achieved or not.
Subjective Data :
Patient might complaints : generalized discomfort,
Body pain, extremities pain, verbalisation for pain, unable to perform daily basis care, excessive behaviour for pain and uneasiness like facial expressions and catatonic reaction.
Objective Data :
Nurse can find out via assessment of patients behaviour and vital signs and symptoms and ask for pain’s location, intensity or severity, frequency and duration. That indicates generalized body and extremities pain with fever. And use data obtained by pain scale.
1 Acute pain related to inflammatory response of body cells to disease conditions as evidence by tachycardia, pyrexia and facial expressions and expressive behaviour.
Short Term Objective: patient feels better after 30 minutes of nursing care or interventions
Long term objective: patients fever and pain should be relieved and cure and any complications by pain or inflammation should be prevented.
1 Provide assessment to the patient and take vital signs and asses by pain scale. For baseline data.
2 Provide comfortable position to the patient as semi fowler position and provide cool and calm environment to the patient
3 Windows and doors are open and air ventilation by fan are provided.
4 Provide aseptic care to the patient and advice patient to take rest.
5 Provide aroma as well as oil massage therapy to extremities.
6 Recheck Vital signs for assess body temperature tachycardia and blood pressure.
7 If fever found consistent provide cold sponge to the patient.
8 Provide analgesic medication as prescribed by physician to lower pain and inflammatory symptoms.
9 Provide guided imagination therapy to the patient for lower pain level.
10 Muscle relaxation therapy should be given to patient.
11 Music therapy should be given to patient.
12 Assess patients pain status, conditions of patients and give assurance to the patient.
Patient is complaining that she/he has pain in the knee joint and he is not able to move his joint and feet. And also they can complaints it’s hurt when any thing likes blanket and bedsheets or any external thing get touch.
After observation and assessment nurse can find the following data: knee joint and toe swelling, previous history of problems and any injury to knee and redness to the area. And sign of gout inflammatory reaction in joint.
2 Alteration in comfort related to uneasiness due to pain arising from medical problems or superficial injury as evidence by tissue swelling and inflammatory sign and pain scale score 8 out of 10.
Short Term Objective: patients pain level should be lower from 8 to 4 after 2 hours of nursing care. And within 2 days she/he can mobilize his toes and joint during treatments.
Long term objective: patients gout attack should be prevented and help to minimize uric acid levels. And survive better in home and home care health education should be given.
1 Assessment should be done to the patient for detection of reasons of uneasiness and assess pain scale every 2 hourly.
2 Provide air conditioning and Cool, calm and noise free environment and atmosphere.
3 Provide good counseling and calmness and psychological support to the patient.
4 Provide cold application to the joint area and then apply antiinflammatory ointment dressing.
5 Provide Anti inflammatory and analgesic medication as prescribed by physician.
6 Provide Allopurinol Medicine as prescribed by patients to lower uric acid crystallization.
And colichine 0.5 mg BD as prescribed by MD doctor to lower gout pain and swelling.
7 Provide Psychological cognitive therapy guided imagery therapy should be given.
8 Relaxation therapy should be given.
9 Deep breathing exercises should be followed.
10 Diversional activities should be implemented to distract his mind from pain and lower the pain level.
Patient complaints that he is having body pain with warm feelings and discomfort to take rest. And feeling oral dryness.
After my observation by vital signs and pain scale the she/he has temp 101°f and 118 pulse rate and pain score was 5 by pain scale. And she/he has the dry oral mucosa and lower skin integrity.
3 Risk for fluid Volume deficient related to dehydration due to pain and hyperthermia as evidence by skin turgidity and dryness of oral mucosa.
Short Term Objective: after 2 hours of nursing interventions patient’s pain and temperature should be minimal and within 24 hours of nursing care patients dehydration should be prevented.
1 Assessment should be done by Braden Scale of the patient and pain scale and vital signs
2 Monitor Intake and output chart of the patient and make patient comfortable by providing comfortable position and calm, cold, ventilated atmosphere lower hyperthermia.
3 provide tepid sponging and acetaminophen by prescription of doctor.
4 Provide mucous shoothing jelly or ointment to the lips and skin.
5 Provide plenty of oral fluids to the patient and plan a liquid diet & give to the patient.
6 Provide oil massage or aromatherapy to the patient to relieve body pain.
7 Provide IV fluids if indicated by prescription.
8 Provide a bed bath to the patient if patient unable to ambulation. And repeat these steps after bathing.
9 Reassessment of vital signs and pain scale and Braden scale should be done. To give assurance to the patient and patient’s relatives.
Patient may States that he is extremely discomfort due to pain. He can express exaggerated, irritable behaviour due to uneasiness by pian.
After nursing observation nurse can find out some of the objective data is vital unstable increase pulse rate increase blood pressure increases respiratory rate due to pain.
4 Risk for injury related to uneasiness and discomfort as evidence by hyperkinetic, restlessness behaviour due to pain.
Nursing Goal :
Short Term Objective: patient should be prevented from any injury due to hyperactive behaviour. Patient pain should be minimised within 24 hours after nursing care.
Long Term Objective: Patient’s pain should be cured and his hyperactive behaviour will be prevented and help to cope up with pain in future.
Nursing Interventions :
1 Asses the patient’s behaviour and it’s causes and focus on pain and record it’s intensity, duration, and type of pain.
2 Provide comfortable position to the patient as semi fowler position given to ease of deep breathing to patient.
3 Provide calm and cold environments and avoid noxicious stimulus.
4 Provide Psychological support and give counseling and health education regarding disease coping skills.
5 Provide mind diversional therapy and relaxation therapy.
6 Provide deep breathing and passive exercise to relive pain.
7 Provide analgesic and antipyretic medication as prescribed by doctor.
8 Provide meditation and mindfulness to the patient to calm down his hyperactive behaviour as well as his pain.
5 Impaired comfort related to acute pain
6 impaired physical mobility related to restriction of mobilization due to pain.
7 Impaired walking related to immobiliser plaster dressing to fractured tibia bone for pain.
8 Impaired wheelchair mobility.
9 Impaired bed mobility.
Short term objective: patients will be coped up with acute pain and understand the scenario of nursing care. And will co-operate with nurses to deal with pain.
Long Term Objective: patients will be freely movable his restriction body parts. He can mobilize his arms and legs. He can walk and and start normal living.
Short Term Basis:
1 provide assessment and range of motion exercises.
2 Provide comfortable position and cool and calm atmosphere to lower panic behaviour.
3 Provide all type of cognitive behavioral therapy to alleviate suffering of pain.
4 Provide a well guidance and counseling with Psychological support.
5 Physiotherapy should be followed regularly.
6 Assist patients in his/her daily routine care.
Long Term Basis:
7 Provide a detail health education regarding suffering, disease conditions and treatment plan.
8 Provide regular follow up with medication and home care.
9 Provide Diet planning according to disease to prevent its complications.
10 Provide protective measures to prevent risk factors of disease.
Nursing care plan for pain images and PPT
The nursing care plan is systemic organised efforts by nurses to deliver nursing care to the patient.
In nursing care plan every step (ADPIE) is taken with scientific evidence and rational that is evident based nursing care.
This is all about nursing care plan (NCP) for acute pain or nursing care plan for hyperthermia and It is all NANDA nursing diagnosis for Pain management.