St.

Paul University Philippines

Tuguegarao City 3500 Cagayan

School of Nursing and Allied Health Sciences

College of Nursing

Nursing Care Plan

Assessment Diagnosis Planning Intervention Rationale Evaluation

SUBJECTIVE: Acute pain related NOC: NIC:
to tissue trauma as PAIN RELIEF: PAIN Goal Met:
She complains of evidence by Use of non- MANAGEMENT
menstrual- cramps- verbalizations pharmacological
like pain in the complaining pain-relief
lower abdomen. menstrual cramps. strategies. The nurse To gain the trust of
established rapport the patient
with the patient and involved.
therapeutic
OBJECTIVE: GOAL: communication.
The client stated
-Pulse rate is 98 After 4 hours of that the pain she
b/m nursing intervention felt earlier
-Respiration Rate is the client’s pain decreases
24 c/m will be decreased. The nurse To detect any
-Blood Pressure is monitored and changes or
95/60 mmHg recorded the deterioration on
-Temperature is After an hour of patient’s vital signs. vital signs. The client learned
37.7 C nursing some of the non-
-Fundus is palpated intervention, the pharmacologic
at U-2, firm and client will be able techniques (e.g,
located at the to demonstrate the relaxation, guided
midline. use of appropriate imagery, music
-Lochia is heavy relaxation Established an To gain patient’s therapy, distraction,
and bright red in techniques and non atmosphere of trust and have a and massage).
color (considered as analgesic relief respect, openness, good nurse-patient
rubra). measures. trust and relationship
-Perineum is intact collaboration.
without swelling,
discoloration or
drainage. Performed a To described by the
comprehensive
client in order to
After an hour of assessment of pain The
nursing to includes; plan effective client composed
intervention, the location, herself and
treatment.
client will be able characteristics, stayed calm for
to compose herself, onset, duration, the rest of the
and stay calm. frequency, quality, hour.
intensity, or
severity and
precipitating factors
of pain.
The client will be The client
able to verbalize Render physical Ensures physical verbalized “pain
“pain relief, and comfort for the comfort allow the relief and free from
free from patient patient to discomfort”.
discomfort” concentrate on
what is being
discussed or
demonstrated.
Perform proper To demonstrate
nursing intervention measures to the
and appropriate patient that
procedures to implemented to
alleviate pain. prevent infections.

To help client cope

Discuss pain
towards the proper
control.
pain management
thus minimizing
pain suffering.
 St. Paul University Philippines
Tuguegarao City 3500 Cagayan

School of Nursing and Allied Health Sciences

College of Nursing

Nursing Care Plan

Assessment Diagnosis Planning Intervention Rationale Evaluation

SUBJECTIVE: Knowledge NOC: Knowledge: NIC: Teaching:
She complains of Deficit regarding Health Behavior Behavior Goal Met:
menstrual- cramps- condition, related Management
like pain in the to lack of
lower abdomen. information and GOAL:
exposure After an hour of After an hour of
nursing intervention, The nurse To gain the trust of nursing
OBJECTIVE: the client will be able established rapport the patient intervention, the
-Pulse rate is 98 to learn about the with the patient and involved. client learned about
b/m pathophysiology of therapeutic the
-Respiration Rate is the diseases. communication. pathophysiology of
24 c/m the diseases
-Blood Pressure is
95/60 mmHg
-Temperature is The nurse To detect any
37.7 C The client will be monitored and changes or
-Fundus is palpated able to know the recorded the deterioration on The client
at U-2, firm and usual signs and patient’s vital vital signs. learned some of
located at the symptoms of the signs. the usual signs
midline. disease, in the right and symptoms of
-Lochia is heavy way. the diseases, in
and bright red in the right way
color (considered
as rubra).
-Perineum is intact Established an To gain patient’s
without swelling, After nursing atmosphere of trust and have a The client was able
discoloration or intervention, the respect, openness, good nurse-patient to verbalize nursing
drainage. client will be able to trust and relationship process on her own
verbalize her own collaboration. understanding.
understanding the
disease process.

Assess readiness to SO may need to

learn and individual suffer
After nursing learning needs: consequences of The client was able
intervention, the - Ascertain level lack of knowledge to enumerate ways
client will be able to of knowledge, before she is ready on how to prevent
enumerate ways on including too accept the recurrence of
how to prevent the anticipatory information. the disease.
recurrence of the needs.
disease:
a. Proper
Hygiene
b. Proper Hand Render physical Ensures physical
Washing comfort for the comfort allow the
c. Diet patient patient to
Modification concentrate on
d. Proper what is being
environmental discussed or
sanitation demonstrated.

Explained the Provide adequate

pathophysiology of knowledge base
the disease and from which client
how it relates to can make informed
anatomy and and
physiology, in the knowledgeable.
right way.

Encouraged Question facilitate

questions. open
communication
between patient
and health care
professionals and
allow verification
of understanding.

Helped patient in Learner makes

integrating adjustment in daily
information into life that will result
daily life in the desired
change in behavior
Helped patient Community
identify community resources can offer
resources for financial,
continuing educational
information and support.
support.