Nursing Care Plan
Acute pain related to movement of bone fragments and injury to the soft tissue as evidenced by:
Pain at left arm graded as 4 using the Numeric Pain Rating Scale
Facial grimace noted when moving left arm,
Decreased tolerance to activity
Goal of Care Intervention Rationale Done or Not
Done
Patients Response
After 2 days of clinical
duty the client will be
able to:
a. Verbalize relief
of pain from the
rate of 4/10 to
1/10
b. Verbalize relief
of pain.
c. Display relaxed
manner; able to
participate in
activities,
sleep/rest
appropriately.
d. Demonstrate use
of relaxation
skills and
diversional
activities as
indicated for
individual
situation.
INDEPENDENT
a. Assessment
Assess pain
location, quality,
timing, duration,
aggravating
factor sand
alleviating
factors
Assess the
severity of pain
through the Pain
Rating Scale
from 0-10
b. Therapeutic
Maintain
immobilization of
affected part by
means of bed
rest, cast, splint,
traction.
This serves as a guide for
choosing the right
interventions for the client
and future evaluation of
the condition.
Serves as indicator if pain
alleviates and efficacy of
pain medications.
Relieves pain and
prevents bone
displacement/extension of
tissue injury.
DONE
DONE
DONE
Elevate and
support injured
extremity.
Lessen activities
during the acute
phase of the
condition
c. Health
Teachings
Teach client to
maintain proper
posture
Teach client
some relaxation
activities
COLLABORATIVE:
a. Assessment
Assess the
efficacy of
medications
ordered by the
physician
b. Therapeutic
Administer pain
medications as
indicated
Administer
muscle relaxants
as indicated
Promotes venous return,
decreases edema, and
may reduce pain.
Reduces muscle spasms
and further injury to the
affected area
Prevents further injury on
the affected arm and
reduces stress on the
muscles affected.
This will distract the client
towards the sensation of
pain as well as alleviate
muscle spasms.
Determines if drug
administered is effective or
not.
Decreases pain sensation
of the client
Relaxes striated muscles
thus decreasing muscle
spasms and pain.
DONE
DONE
DONE
DONE
DONE
NOT DONE
NOT DONE
Administer anti-
inflammatory
medications as
indicated
c. Health
Teachings
Teach client to
report any
adverse
reactions to the
pain medications
Reduces the inflammation
the slipped disc thus
reducing lower back pain.
Determines if client is
hypersensitive to the drug.
NOT DONE
DONE
Impaired physical mobility related to loss of integrity of bone structures evidenced by:
Hand grasps graded 2/3
partial range of motion on upper and lower extremities
Goal of Care Intervention Rationale Done or Not
Done
Patients Response
After 2 days of clinical duty the
client will be able to:
a. Increase muscular
strength
b. Verbalize
understanding on
current condition
c. Demonstrate
activities which
could regain
physical mobility
d. Maintain position of
function and skin
integrity as
evidenced by
absence of
decubitus ulcers
INDEPENDENT
a. Assessment
Assess factors
which serve as
barriers to
physical mobility
Assess the skin
integrity
especially in the
pressure points
of the body
b. Therapeutic
Provide good
skin care
Assist client in
changing
positions
Assist with
passive ROM
exercises
Determines the
specific factors which
aggravate the
immobility of the
client.
Determines if skin on
pressure points are at
risk for pressure
ulcers.
Prevents occurrence
of pressure ulcers on
immobilized pressure
point.
Decreases stress and
straining in injured
body part.
Strengthens
weakened muscles
during immobility.
DONE
DONE
DONE
DONE
DONE
Assist with
gradual
ambulation
c. Health
Teachings
Teach client to
increase oral
fluid intake
COLLABORATIVE:
a. Assessment
Assess the
efficacy of pain
medication
before the time
of ambulation
b. Therapeutic
Administer pain
medications
before exercises
and as indicated
c. Health
Teachings
Advice client to
drink pain
medications
before
ambulation or
passive ROM
exercises.
This will encourage
progressive
ambulation and
mobilization of client.
Decreases chances of
skin break down on
immobilized body
parts.
Determines if client is
suited and can
tolerate to perform
exercises.
Decreases
occurrence of pain
during mobilization.
Decreases
occurrence of pain
during exercises.
DONE
DONE
DONE
DONE
DONE
