PHINMA UNIVERSITY OF PANGASINAN
COLLEGE OF ALLIED HEALTH SCIENCES - DEPARTMENT OF NURSING
NURSING CARE PLAN
ASSESSMENT
Subjective:
The patient states
that he has been
having consistent
pain in his right
shoulder for a
month.
Objective:
-Reluctance to use
affected shoulder
- History of severe
right sided shoulder
pain
- Overweight 29 kg.
- Pain scale of 7/10
Vital signs:
T: 36.5 C
P: 73
R:20
BP: 120/70 mmHg
DIAGNOSIS
Chronic pain
related to disuse of
muscles as
evidenced by
patient reports
history of severe
right sided
shoulder pain.
INFERENCE
PLANNING
Pain can be
At the end of shift, the
considered acute or
patient will be able to:
chronic. Chronic pain
- Report decrease in
occurs when pain
pain scale of 7/10 to a
signals continue to fire
manageable level of
in the nervous system.
2/10
This is ongoing, lasting
- Maintain acceptable
longer than the typical
pain level
healing timeframe
- Patient demonstrates
which is typically
measures to increase
defined as pain that is
mobility
on
the
present for longer than
affected side.
3-6 months. Every
person will experience
pain differently and
every individual’s
tolerance for pain will
be different. Overtime,
constant pain can begin
to affect other areas of a
person’s life including
their daily activities.
Likewise, individuals
suffering from chronic
pain are also at an
increased risk
of depression and anxie
ty. Individuals may also
INTERVENTION
1. Assess the patient for shoulder
stiffness, pain
2. Assist the patient when
changing position
3. Position the shoulder of the
patient appropriately.
4. Assist the patient in performing
range of motion exercises.
5. Use complementary and alternative
medicine therapies as appropriate (i.e.
massage, ice packs, heating pads).
6. Administer analgesics as
prescribed.
RATIONALE
1. Hemiplegic shoulder
pain (HSP) is a
common and
distressing
complication related to
stroke and occurs in
the paralytic side of the
patient
2. Using an appropriate
force when turning or
changing the patient’s
position will prevent it
from overstretching the
affected shoulder joint.
3. Many shoulder
problems can be
prevented by proper
patient movement and
positioning.
4. ROM exercises are
essential in preventing
shoulder stiffness, thus
preventing pain.
5. Some therapies such as
massage may help decrease
patient’s pain level. In
EVALUATION
At the end of shift, goals are
met as evidenced of patient
reports decrease in pain scale
from 7/10 to 2/10. Able to
accept pain level and
demonstrated some measures
to increase mobility on the
affected side.
begin
experiencing sleep
disturbances due to the
pain they experience.
addition, the use of hot or
cold therapy may assist in
keeping pain at a more
manageable pain level
6. If the provider has
ordered pain medications this
may be helpful in controlling
the patient’s pain.
Administering pain
medication should be based
on the pain assessment.
SUBMITTED BY:
SUBMITTED TO: