Nursing Care Plan - Acute Pain 586y5j

Nursing Care Plan Assessment Subjective: “Masakit ang dibdib ko” as verbalized by patient. Objective: · Use of accessory muscle. · Dyspnea · Fatigue.

Diagnosis

Planning

Intervention

Rationale

Evaluation

Acute pain r/t localized inflammation and persistent cough.

• After 4 hours of nursing intervention the patient will display patent airway with breath sounds clearing and absence of dyspnea.

Independent: • Elevate head of the bed, change position frequently. • Assist patient with deep breathing exercises. • Demonstrate or help patient learn to perform activity like splinting chest and effective coughing while in upright position. • Force fluids to atleast 3000 ml per day and offer warm, rather than cold fluids.

• Lowers diaphragm, promoting chest expansion and expectoration of secretions. • Deep breathing facilitates maximum expansion of the lungs and smaller airways. • Coughing is a natural self cleaning mechanism. Splinting reduces chest discomfort, and an upright position favors deeper, more forceful cough effort. • Fluids especially warm liquids aid in mobilization and expectoration of secretions. • Aids in reduction of bronchospasm and mobilization of secretions. • Fluids are required to replace losses and aid in mobilization of secretions.

• After 4 hours of nursing intervention patient was able to display patent airway with breath sounds clearing and absence of dyspnea.

Collaborative: • ister medications as prescribe: mucolytics or expectorants. • Provide supplemental fluids.