NURSING CARE PLAN (NCP)

Nursing Dx 1: Acute Pain Related to tissue injury as evidenced by redness, lesions, and
inflammation in both hands and facial grimace.
Goal: The client will verbalize pain relief.
Specific Objectives: After 8 hours of nursing interventions, the client will be able to:
 verbalize relief of pain from 7 to 3 on a Pain Rating Scale
 use pharmacological and non-pharmacological strategies to relief pain.

Cues Nursing Intervention with Rationale Evaluation

Subjective: Independent Rationale Goals met. The

Patient verbalized “ Masakit client verbally
1. Perform a Assessment is the first
and alima” reported pain relief
comprehensive step in managing pain,
from 7 to 3 (severe
assessment. Assess it helps ensure that the
to mild pain) on a
Objective: location, characteristics, patient receives
Pain Rating Scale.
 Presence of flaky onset, duration, frequency, effective pain relief.
Client uses non-
skin. quality and severity of
pharmacological
pain.
 Inflammation of both and
hands. Fears, concerns can pharmacological
 Presence of lesions 2. Encourage verbalization lower threshold of strategies to relief
noted in both hands. of feelings about the pain. pain perception. the pain being
experienced such
 Redness noted in both
as putting warm
palm.
3. Assess the client’s compress and take
 Facial grimace observed. Aids in planning and
current use of medications. obtaining medication analgesic as
 Pain scale of 7 out of 10 ordered.
history.
Vital signs
4. Encourage adequate
BP: 118/78 mmHg
rest. To provide comfort.
Temp: 35.7 ̊c
PR: 68 bpm
5. Provide comfort
RR: 18 cpm
measures such as use of To provide non-
warm compress. pharmacological pain
management.

6. Cleanse wound daily. To promote healing

Cues Nursing Intervention with Rationale Evaluation

and help prevent

infection

7. Evaluate the To assess effectively

effectiveness of pain of pain management
control measures. and its process.

Dependent Rationale

Administer analgesic as For pain relief.

prescribed

Collaborative Rationale
Advice follow-up check up For continued
from other health care assessment monitoring
professionals. of treatment.