COMMUNITY COLLEGE OF PHILADELPHIA
NURSING CARE PLAN
Nursing 101, Fall 2006
Student_____Elaine Tagliareni
Client initials______JP
Age___83 years
Defining
Characteristics/Behaviors
Intensity
Pain Scale :
“My pain is a 6”.
Location
(Mark a drawing or
describe)
Complains of discomfort on
left side; aching in her back
after PT
Onset of Pain
Upon arising and after PT :
Movement makes it worse”.
Duration
Discomfort on left side is
continuous with some relief
after pain medication
Nursing Diagnosis____Pain related to immobility and fatigue
Contributing Factors
Expected Outcomes
(with rationales)
1. Physiological Integrity:
Pathophysiology (Medical
Diagnosis)
Stroke on Left Side (CVA)
(with rationales)
The client will report to the
nurse that her pain is a 0 today.
Rationale: Impaired physical
mobility can result in pain, joint
stiffness and contractures
(Gulanick, 127)
2. Growth and Development
Developmental Norms:
Decrease in sensory
perception
Increased pain threshold
Acute pain may not be
sharply perceived
Mobility will be reduced
( Lecture)
Nursing Interventions
The nurse will
1. Give the client’s pain
medication (Motrin) one hour
before morning AM care and
PT.
Rationale: The peak effect of
Ibuprofen is 1-2 hours when given
PO. (Davis Drug Guide)
The client will verbalize a
sense of control over pain
experience today to the nurse.
2. Provide client with sleep
medication (Restoril) at a time
consistent with previous
pattern.
Rationale: The patient’s
experiences with pain may become
exaggerated as the result of
fatigue (Gulanick, 124)).
3. Walk the client in the hall
1
twice a day.
Quality
Ache or throbbing in left
arm; Soreness in left leg and
arm
Associated Symptoms:
No complaints of
restlessness, listlessness
No observable diaphoresis.
Vital signs remain stable
throughout the day and do not
increase with pain.
3. Care Environment
a. Environment/Hospital
Fatigue: Client states “I am
exhausted”
Rationale: Fatigue heightens the
perception of pain
Change in routine and anxiety
about cold and forgetfulness
Rationale: Anxiety often increases
pain perception and pain also
causes feelings of anxiety .
b. Mobility/Immobility
Client has limited mobility due
to left sided weakness
Rationale: Immobility contributes
to stiffness of joints, decreased
blood flow to body parts which
can lead to pain (Lecture)
c. Medical/Nursing
Treatments
Rationale: Muscle atrophy is a
common complication that arises
from the lack of weight bearing
found with immobility (P&P,
1442; Immobility leads to stiffness
and muscle pain (Lecture).
The nurse will
1. Reinforce the importance of
asking for and taking pain
medication to keep pain under
control.
Rationale:One can most
effectively deal with pain by
preventing it. Early intervention
may decrease the total amount of
analgesic needed. (Gulanick, 124)
2. Teach client to request that
she is wrapped warmly with a
hat and three blankets for PT.
Rationale: Anxiety tends to reduce
pain threshold and limit pain
tolerance); decrease in anxiety
will increase pain tolerance.
Client attends PT daily; ROJM
Rationale: The elderly are
susceptible to injury and more
pain during care activities).
d. Medications
(Pharmacology)
3. Include Angie in care-
2
Motrin q4 horus for pain
planning about managing
discomfort at PT and after
periods of immobility.
Rationale: Action of drug: used
for analgesic effect. Inhibits
prostaglandin release (Lilley,
734).
e. Previous Patterns (if
applicable)
Client has a history of pain
while hospitalized and
experienced pain during
previous hospitalization
Rationale: If a client has
experienced pain or is threatened
by the anticipation of pain, the
pain response is heightened.
(Lecture).
f. Diagnostic Tests (if
applicable)
g. Cultural Influences (if
applicable)
4. Psychosocial Integrity
a. Stressors
Client is experiencing stressors:
New setting (rehab facility)
Pain
Anticipation of pain
Worry about “catching a
cold”
Evaluation of Expected
Outcomes:
Rationale: Involving the family in
pain management increases
compliance with the treatment
regim; adding to the patient’s
network of social supports can
reduce the burden of suffering
with pain. (Gulanick, 129)
The client stated that her pain
was a 0 today.
The client stated that she now
feels a greater sense of control
over her pain even though she
will never be able to fully
control her life while in the
hospital.
3
Overstimulation of eating
with group
Worry about Angie at home
Concern about final
outcome of illness, “Will
I ever be cured?”
Rationale: Anxiety tends to reduce
pain threshold and limit pain
tolerance (P&P, 1238 and
Lecture)
b. Coping Mechanisms
Clients usual coping
mechanisms are use of usual
routines, talking and being with
Angie, caring for self.
Rationale: When a patient
experiences pain in a health care
setting such as a hospital,
loneliness can be unbearable and
coping styles are altered and
influence the ability to deal with
pain (P&P, 1238).
c. Support Systems
Angie is primary support
person
Rationale: An absence of a family
or friends can often make the pain
experience more stressful (P&P,
1238).
4
COMMUNITY COLLEGE OF PHILADELPHIA
NURSING CARE PLAN
Nursing 101, Fall 2004
Student________________________________
Client initials____________________
Defining
Characteristics/Behaviors
Age_______________
Contributing Factors
Nursing Diagnosis______________________________________
Expected Outcomes
(with rationales)
1. Physiological Integrity:
Pathophysiology (Medical
Diagnosis)
Nursing Interventions
(with rationales)
The client will……..
The nurse will…………
The client will……..
The nurse will…………
2. Growth and Development
5
3. Care Environment
a. Environment/Hospital
Evaluation of Expected
Outcomes:
b. Mobility/Immobility
c. Medical/Nursing
Treatments
d. Medications
(Pharmacology)
e. Previous Patterns (if
applicable)
f. Diagnostic Tests (if
applicable)
g. Cultural Influences (if
applicable)
4. Psychosocial Integrity
a. Stressors
6
b. Coping Mechanisms
c. Support Systems
7