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Saint Paul University Philippines: School of Nursing and Allied Health Sciences College of Nursing

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Saint Paul University Philippines

Tuguegarao City, Cagayan 3500

School of Nursing and Allied Health Sciences


College of Nursing

NURSING CARE PLAN

Diagnosis or Clinal Impression: Acute Pain

ASSESSMENT/ NURSING BACKGROUND GOAL AND NURSING EVALUATION


CUES DIAGNOSIS KNOWLEDGE OBJECTIVES INTERVENTONS
AND RATIONALE
Subjective: Acute pain r/t Acute pain is an NOC: NIC: The patient was
Rated his pain swelling and unpleasant Pain Level Pain Assessment able to verbalize
10/10 when gout destruction of sensory and Pain Management that the pain was
attacks the joints as emotional Goal: The relieved
evidenced by experience patient will be >Assess patient controlled from
Celecoxib growing tophi. associated with able to verbalize complains of pain by 6/10.
200mg/cap 2x a actual or potential that the pain is its location, onset,
day (pain reliever tissue damage, or minimized and time course, The patient was
and anti described in terms controlled from character, severity, able to determine
inflammatory) of such damage 10/10 to 6/10 as radiation, and factors and execute pain
(International evidenced by the for relief and management
Colchicine Association of the absence of exacerbation. techniques.
500microgram/tab Study of Pain); guarding -Essential in
1x a day (block the sudden or slow of behavior, facial identifying pain
effect of high uric any intensity from grimaces and management needs.
acid) mild to severe with the ability to
an anticipated or walk. >Document presence
Febuxostat predictable end, of pathophysiological
80mg/tab ½ tab a and with a causes of pain.
day (lower down duration of less Objectives: - Affects choice of
blood uric acid than 3 months. intervention for pain
level) The patient will management.
be relieved from
Applying Aescin pain. >Acknowledge the
Diethylamine pain experience and
salicylate on The patient will convey acceptance
swollen areas when be able to of client’s response
necessary determine and to pain.
execute pain -Reduces defensive
Objective: management responses, promotes
techniques. trust, and enhance
He has a known cooperation with
gouty arthritis regimen.

Swelling >Observe for non-


verbal cues and pain
Tophi on joints behaviors.
-Observation may not
Difficulty of moving be congruent with
and walking verbal reports or may
be an indicator
Guarding behavior present when client
is unavailable to
Facial grimaces verbalize.

>Note for patient’s


attitude towards pain,
locus of control,
acceptable level of
pain.
-To identify the
manageable and
unmanageable level
of discomfort of the
patient.

>Determine factors in
patient’s lifestyle.
-Protects against
gout attacks and
avoids gout trigger

>Provide the patient


comfort measures
such as repositioning
or elevating the
gouts, applying ice to
the joints, giving
plenty of water to
drink.
-Promoting comfort
and
nonpharmacological
pain management.

>Establish
collaborative
approach for pain
management
techniques such as
use of pain
medications or taking
prescribed drugs.
-Helps in relieving
patient’s pain

>Demonstrating
ways of good body
mechanics.
-Helpful for
minimizing pain

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