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Assessment
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Nursing
DX/Clinical Problem
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Client
Goals/Desired Outcomes/Objectives
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Nursing
Interventions/Actions/Orders and Rationale
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*I
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Evaluation
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Subjective
PR stated she has ‘headache that interferes with my daily activities.” She also
said she felt weak.
Objective
Client
had frown on her face.
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Problem
Chronic Pain
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Long Term:
Client will identify specific pain level that will allow her to perform ADL’s, and
pain will stay below the specific lever for remainder of cancer progression.
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-In addition
to analgesics, support the client’s nonpharmacological methods to help control pain,
such as PT, group therapy, distraction, imagery, relaxation, massage and heat/cold
applications. Rationale: Cognitive-behavioral strategies can restore the client’s
sense of self-control, personal efficacy, and active participation in his or her
own care.
-Explore appropriate
resources for management of pain on a long-term basis (Hospice, Pain care center)
Rationale: Most clients with cancer are treated for pain in outpatient and home
care settings for increase comfort for client.
- Assist client
and family in minimizing effects of pain on interpersonal relationships and daily
activities such as work and recreation. Rationale: Pain can reduce patient’s options
to exercise control, diminish psychological well-being, and make them feel helpless
and vulnerable. Therefore clinicians should encourage active client involvement
in effective and practical methods to manage pain.
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Client reported decreased
pain by using relaxation techniques, and visiting an outpatient pain clinic.
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R/T
Tumor progression and related pathology
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Short Term:
Client’s comfort level will increase within one day of hospital stay and client
will be able to rest continuously for 7+ hours each night.
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-Assume that pain is present and treat accordingly in
clients who have a pathological condition. Rationale: Pain is associated with certain
pathological conditions and should be assumed that pain is present and treated accordingly.
-For persistent mild cancer, obtain a prescription to
administer nonopioid analgesics. Rationale: A multimodal approach combining analgesics
that attack different underlying pain mechanisms is recommended for the treatment
of persistent cancer pain.
-Watch for signs of depression with chronic pain; sleepiness,
not eating, flat effect, statements of depression, or suicidal ideation. Rational:
Clients with chronic pain had twice the rate of suicide than the people without
pain.
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Clients pain level has decreased with the use of opioids and can sleep 7+ hours
each night. Client has increased doing her own ADL’s
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