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

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