Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

Complains of tenderness and edema in lower extremity.

Objective

Open reduction and internal fixation of Left femur 2 days ago.

Grimacing, patient rates pain as a 4 on scale of 0-10, guarding of lower extremity, and increase in respirations.

Problem

Acute pain

Long Term:

Patient will perform activities of recovery with acceptable level of pain. Pain should level should stay at a 3 or less on a scale of 0-10

Attempt to keep pain at a level that will allow the patient to achieve functional and quality of life goals (Ackley and Ladwig, 2008, p 604).

*

Goal met- patient was able to change position while being able to control the pain.

Continue to help patient ambulate and keep acceptable pain level while being able to help with quality of life goals.

R/T

Venous congestion, impaired venous return, and inflammation

Short Term:

Patient will rate pain as a 2, or lower, on a scale of 0-10 by the end of the shift

Assess pain level and severity every 4 hours by patient self report (Ackley & Ladwig, 2008, p 604)

*

Goal met- patient rates pain as a 1 on a scale of 0-10 one hour after hyrocodone 5mg/acetaminophen 325 mg were given. Pain level still reported as 1 out of 10 at end of shift.

Continue to monitor pain and assess pain rating as listed.  Use distractions and reposition at least every 2 hours.

AEB

Grimacing, patient’s pain rating, and previous surgery.