Nursing Care Plan for Acute Pain and Post-Traumatic Stress Disorder

This document provides a nursing care plan for managing acute pain and post-traumatic stress disorder (PTSD). It includes assessment, interventions, and evaluation for these conditions. The plan focuses on pain assessment, medication administration, wound infection prevention, self-care deficit, anxiety reduction, and management of post-traumatic stress disorder. The document also discusses coping strategies, identification of triggers, and education for patients.

Nursing are Plan for: Student: Date:
Medical Diagnosis:
Definition of Medical Diagnosis:
NANDA
Nursing
Diagnosis and
Support Data
Goal/Outcome
Criteria
(at least
1/diagnosis)
Nursing
Interventions
(at least
3/goal)
Scientific
Rationale/Principle
(with reference)
Evaluation
of
Intervention
Acute pain
related to
physical
injuries
Support Data
(subjective,
objective,
assessment)
Evidenced by
wincing at any
movement and
guarding
behavior
Patient reports
less pain and
displays
normalized
vital signs and
relaxed
posture.
Assess
patient’s pain
characteristics
such as
duration,
severity and
quality
Immediately
recognize pain
reports from
the patient
Pain assessment is
the foremost step in
pain management
and the patient and
the patient provides
the best information
regarding their pain
(Jungquist et al,
2017).
Immediate response
to pain alleys a
patient’s anxiety and
leads to a trusting
patient-nurse
relationship (Booker,
Pain levels
decrease to a
level below 3
to 4 on a pain
rating scale of
0 to 10.

Provide
analgesics like
non-steroidal
anti-
inflammatory
drugs for pain
relief
2016).
Non-steroidal anti-
inflammatory drugs
inhibit COX-1 and
COX-2 enzymes
which synthesize
prostaglandins which
play a major role in
inflammation
thereby relieving
pain(Wong, 2019).
The risk for
infection
related to open
wounds
Support
Evidenced by
the presence of
bruises on her
extremities
Reduce risk for
infection
Wound
dressing
Drug
Dressing reduces the
risk of infection by
preventing the entry
of microorganisms
that cause infection
(Negut,
Grumezescu,&
Grumezescu, 2018)
Administration of
The patient
will be able
to identify
signs and
symptoms of
infection
The patient is
able to adhere
to prescribed

administration
Monitor signs
and symptoms
of infection
prescribed
medication reduce
chances of infection
by acting as
prophylaxis
Signs and symptoms
allow the nurse to
take necessary
measures to curb
infection and take
necessary preventive
measures.
medication
Patient
understands
precautionary
measures of
infection
prevention.
Self-care deficit
related to
musculoskeletal
impairment.
Supporting
Data
Evidenced by
Fractured right
Patients
implements
activities of
self-care to
optimal
capability.
Boost patient’s
independence
by supervising
activities of
daily living
until the
patient is
effectively
skilled to
perform
independent
self-care.
Supervision allows
the nurse to assess
the patient’s needs
which change as they
progress with
treatment and adjust
interventions
accordingly
The patient
will be able
to perform
activities of
daily living
with reduced
effort

arm Encourage
independence
by positive
reinforcement
for all
activities
performed by
patients
Come up with
self-care
routines for
the patient to
perform and
give ample
time to
complete the
tasks
Positive
reinforcement is
bound to encourage
the patient to put
more effort into self-
management
especially when
progress is slow
(Pulvirenti,
McMillan &
Lawn,2014).
When a routine is
established, it
becomes habitual
and easier to do as
time progresses
The risk for
domestic
violence related
The patient
feels safe
enough to share
Identify the
cause and
signs of
Identification of the
cause of anxiety is
vital for identifying
Patient
experiences
reduced

to previous
medical history
suggestive of
abuse
Supporting
Data
Evidenced by
the patient’s
protective
behavior,
anxiety and
evident fear of
the husband
the history of
abuse
The patient is
in a secure
environment
increased
levels of
anxiety
Discuss
coping
strategies for
dealing with
anxiety and
stress
Observing and
adjusting the
environment
to remove the
cause of
violence to the
patient
the best intervention
strategies for the
patient
Coping strategies
such as
psychotherapy can
assist the patient in
dealing with stressful
situations they may
face.
Removing the cause
of violence to the
patient can ensure
eradication of
possible harm to the
patient (Alshammari,
Mc Garry and
Higginbottom,
2018).
anxiety and
emotional
and physical
safety
The risk for Patient Provide The patient will be The patient is

Post-Traumatic
Stress Disorder
related to
sexual abuse
Supporting
Data
Evidenced by
vaginal trauma
upon physical
examination
demonstrates
recovery from
violence and
abuse
patient
education on
symptoms of
PTSD
Establish a
trusting
relationship
with the
patient
Provide
prophylactic
medication to
the patient
following
evidence of
sexual abuse
able to identify,
understand and act
on symptoms of
PTSD, thus reducing
anxiety
A trusting
therapeutic
relationship will
allow the patient to
identify coping
mechanisms and
restore trust
Prophylaxis for STIs
protects the patient
from further
infection.
able to
manage
symptoms of
PTSD
The patient
does not
suffer from
sexually
transmitted
infections
Anxiety related
to financial
instability
The patient
recognizes
anxiety-
Assist patient
in identifying
precipitants of
Identifying triggers
for anxiety allows
the patient to avoid
The patient is
able to
identify

Supporting
Data
Evidenced by
the patient’s
lack of source
of income
reduction
strategies
anxiety
Provide
education
about coping
strategies
Provide
assistance to
the patient in
developing
strategies to
reduce anxiety
them and evaluate
the best way to deal
with anxiety
(Alshammari,
McGarry, &
Higginbottom, G.
2018 )
The patient will have
increased confidence
regarding ways to
deal with anxiety.
New methods of
managing anxiety
provide the patient
with a variety of
ways to cope
anxiety
precipitants
and manage
the signs and
symptoms
effectively.

References
Jungquist, Carla R., et al. “Assessing and Managing Acute Pain.” AJN, American
Journal of Nursing, vol. 117, no. 3, 2017.
Booker, S. Q., & Haedtke, C. (2016). Assessing pain in verbal older
adults. Nursing, 46(2), 65– 68.
Alshammari, K. F., McGarry, J., & Higginbottom, G. (2018). Nurse education and
understanding related to domestic violence and abuse against women: An
integrative review of the literature. Nursing open, 5(3), 237–253
Negut, I., Grumezescu, V., & Grumezescu, A. M. (2018). Treatment Strategies for
Infected Wounds. Molecules
Pulvirenti, M., McMillan, J., & Lawn, S. (2014). Empowerment, patient centred care and
self-management. Health expectations : an international journal of public
participation in health care and health policy, 17(3), 303–310
Rebecca S. Y. Wong. (2019). “Role of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
in Cancer Prevention and Cancer Promotion,” Advances in Pharmacological
Sciences.