Nursing Care Plan


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Medical Diagnoses: Chronic Pain

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

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.


Problem

   

Chronic Pain

   

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.

-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.

   

   

-          Client reported decreased pain by using relaxation techniques, and visiting an outpatient pain clinic.


 

   

R/T

   

Tumor progression and related pathology

   

   

   

   

   

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.


-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.

   

-          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

   

AEB

   

Patient stating pain of 7 on scale of 1-10 and headache pain that interferes with ADL’s and decrease in sleep

   

   

   

   

   

   

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*I = Implementation.  Check those interventions/actions/orders that were implemented.


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