Nursing Care Plan

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Medical Diagnoses: Acute Pain , UTI diagnosis

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

 

Pt states that she is in pain in her “private area”.

 

 

Objective

   

Pt states her pain level is 7 out of 10 on the pain scale.

   

Insertion of foley catheter

   

Diagnosis of UTI

   

Pt demonstrates grimaces and guarding

Problem

   

Acute Pain

   

   

Long Term:

Pt will verbalize understanding of pain management plan by discharge.

*Educate the pt on the importance of taking medications to keep pain under control.

   

Rationale: “Teaching the patient to stay on top of their pain and prevent it from getting out of control improves the ability to accomplish the goals of recovery.” (Ackley & Ladwig, 2008, p. 610)

   

* Develop a treatment plan with the pt.

   

Rationale: “Client input into the plan of care improves the likelihood of successful management.

   

*Educate the pt on non-pharmacological approaches for pain control.

   

Rationale: “Nonpharmacological interventions are used to complement, not replace, pharmacological interventions.” (Ackley & Ladwig, 2008, p. 610)

   

   

   

   

   

   

   

   

   

I

Pt goal met. Pt was able to verbalize her understanding of her pain management plan to the staff. Pt was able to explain to the staff the measures she was taught to effectively control her pain. Pt comprehends the needed measures to control her pain at home. Pt stated that she thinks she can control her pain levels by herself at home now.



Continue interventions as listed. Continue to educate the pt on the importance of taking her medications to control her pain. Continue to assist in developing a thorough treatment plan with the pt. Continue to reinforce the importance of using nonpharmacological measures to control pain.

R/T

 

 

UTI diagnosis

 

 

 

 

Short Term:

Pt will report a decrease in her pain level or <4 out of 10 on this shift.

*Assess pain by using the 10 point pain rating scale q4 hrs or PRN.

 

Rationale: “Single item ratings of pain intensity are valid and reliable as measures of pain intensity.”

“Systematic ongoing assessment and documentation provide direction for the pain treatment plan; adjustments are made based on the client’s response.” (Ackley & Ladwig, 2008, p.604)

 

*Administer medications as ordered.

 

Rationale: “Pharmacological interventions are the cornerstone of management of moderate to severe pain. Unless contraindicated, all clients with acute pain should receive a nonopiod agent around the clock.” (Ackley & Ladwig, 2008, p.605)

 

*Explain to the pt the pain management approach that has been ordered.

 

Rationale: “One of the most important steps toward improved control of pain is a better client understanding of the nature of pain, its treatment, and the role the client needs to play in pain control.” (Ackley & Ladwig, 2008, p.606)

 

 

 

 

 

 

 

 

 

 

I

Goal met. Pt reported a decrease in her pain level that was originally 7 out of 10. Pt was given appropriate medications to relieve the pain. She did not report an increase in pain throughout the day and reported 2 out of 10 by the end of the shift.

Continue interventions as listed. Continue to evaluate the pt’s pain rating using the 10 point pain scale q 4 hrs or PRN. Continue to administer medications as ordered. Continue to reinforce and educate the pt on the pain management she is receiving.

AEB

 

Pt complaints of perineal soreness and pain

 

Pt demonstrates grimaces and guarding

 

Pt rates pain at a 7 on a 10 point pain scale.

 

UTI diagnosis

 

 

 


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

 

References

 

Ackley, B.J., & Ladwig, G.B. (2008). Nursing diagnosis handbook: An evidence-based guide to planning care (8th ed.). St. Louis: Mosby Elsevier.



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