Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

Complaints of fatigue, rectal bleeding and a change in bowel patterns (constipation alternating with diarrhea. The patient has no other significant medical history. He has smoked for most of his adult life; he has an 80 pack/year history. He admits to drinking on the week-ends. He denies the use of drugs. The patient is divorced and has 3 independent adult children and 2 grandchildren. Recently he became engaged and plans to be married within 6 months. His father had colon cancer and died before he was

55 years of age. The patient is a [] and works 40 hours/week. He currently lives with his fiancée. He has been upset and concerned about his health and voices concern about dying as his father did with cancer.

Objective

Temp 99.86

Heart Rate 83

Respirations 20

Pain 6 on 0-10 scale

Lost 5lbs in past few days

Output 400cc

Intake 0cc- NPO

Post AR surgery

Lesion on abdoment 6cmX8cm

An initial work-up

grimace on face and unpleasant mood of patient. revealed anemia, a carcinoembryonic antigen

(CEA) level of 22mg/dl, and a positive computerized technology (CT) scan showing a mass in the sigmoid rectal region

No family at bedside

CBC, electrolytes, BUN, creatinine, glucose-pending

Problem

Acute Pain

Long Term:

Client will describe nonpharmacological method that can be used to help control pain to be evaluated by discharge.

Teach and implement nonpharmacological interventions when pain is relatively well controlled with pharmacological interventions. Nonpharmacological interventions should be used to supplement, not replace, pharmacological interventions (APS, 2004).

Client was not able to describe any type of nonpharmacological treatment by discharge. Goal not met.

Taught patient about different types of nonpharmacological treatment such as relaxing music, distraction and deep breathing on [date]

R/T

Patients status of recent abdominal surgery.

Short Term:

Client will use pain rating scale to identify current pain intensity and determine comfort/function goal (if client has cognitive abilities)  to be measured on a scale of  0-10 and evaluated by [date] at 1430.

Assess pain in a client by using a self-report such as the 0 to 10 numerical pain rating scale, Wong-Baker FACES Scale, or the Faces Pain Scale (see Pain: Assessment Guide and Appendix D). Systematic ongoing assessment and documentation provide direction for the pain treatment plan; adjustments are based on the client's response (Berry et al, 2006). EB: Single-item ratings of pain intensity are valid and reliable as measures of pain intensity (Jensen, 2003). EBN: An investigation of nursing attitudes and beliefs about pain assessment revealed that effective use of pain rating

Client was able to use the pain rating scale of 0-10 to rank pain and pain was of a level 6.

Assessed patient using 0-10 pain rating scale and explained that 0 is no pain and 10 is the worst pain on [date]

AEB

Post AR surgery, grimace on face and unpleasant mood of patient.