NURSING CARE PLAN
Select the top priority nursing diagnosis and complete this nursing care plan.
V. NURSING DIAGNOSIS III. CLIENT DAY OF CARE OUTCOMES (2 to 3)
Acute Pain r/t abdominal surgery to remove hemo-dialysis catheter. A.Patient will use 1-10 number scale to identify current pain level and
establish a comfort-function goal
VI. DISCHARGE OUTCOME(S))
a
Patient will verbalize that they are pain free by rating pain as a 0/10 B.Patient will notify staff when pain level is greater than the
vi
by discharge. comfort-function goal.
Patient will perform activities of recovery or activities of daily living
easily. C. Patient will perform activities of daily living/recovery easily.
e d
IV. NURSING INTERVENTIONS SCIENTIFIC RATIONALE EVALUATION
Assess the client for pain presence routinely at “Pain assessment is as important as Day of Care Outcome(s)
ar
frequent intervals, often at the same time as physiological vital signs and pain is Met Unmet Partially Met
vital signs are taken, and during activity and considered as the “fifth vital sign” (APS, Documentation: (State behaviors that patient exhibited
sh
rest. Also assess pain with interventions or 2008) “Acute pain should be reliably that helped you determine that day of care outcome(s)
procedures likely to cause pain. assessed both at rest(important for were met. Also discuss interventions implemented to
Ask the client to identify a comfort-function goal, comfort) and during movement reach day of care outcome(s).
a pain level, on a self-report pain tool, that will (important for function and decreased Patient verbalized when they had pain and rated on a scale of
as
allow the client to perform necessary or client risk for cardiopulmonary and 1-10, they notified staff in a timely matter. Patient performed
desired activities easily. This goal will provide thromboembolic events.” (Breivik et al, ADL's well, but still unsteady.
2008) pg 601-602
w
the basis to determine effectiveness of pain
management interventions. If the client s “The relationship between pain level and
unable to provide a self-report, it will not be functional goals should be major focus
possible to establish a comfort-function goal. of the development of individualized
m e
Administer supplemental opioid doses as pain management plans” (Pasero &
ordered to keep the client's pain level at or
below the comfort-function goal, or desired
co rc McCaffery, 2004b) “Effective pain relief
with function such as mobilization,
coughing, and deep breathing is critical
Discharge outcome(s)
Met Unmet Partially Met
Documentation: (State behaviors that patient exhibited
o. ou
outcome if the client is unable to provide a
self-report based on clinical judgment or for decreasing risk factors for that helped you determine that discharge outcome(s) met.
behaviors. cardiopulmonary and thromboembolic Also discuss interventions implemented to reach
complications after surgery” (Breivik et discharge outcome(s).
Teach and implement non-pharmacological
er res
al, 2008) “Immobilization also is a major WAS NOT THERE WHEN PATIENT WAS DISCHARGED
interventions when pain is relatively well-
risk factor for chronic hyperalgesic pain FROM HOSPITAL, MAKING ME UNAWARE OF RESULTS.
controlled with pharmacological interventions.
after surgery” (Stubhaug&Breivik, 2007) RESULTS UNKNOWN.
“An order for prn supplementary opioid
eH y
doses available to provide appropriate
pain relief” (Pasero, Manworren, &
rs ud
McCaffery 2007; APS, 2008)
All interventions/rationale from Nursing Diagnosis “Non-pharmacological interventions
Plan Updates: (Include new interventions, change in
Handbook. Ackley, Ladwig. Pgs 323-328 should be used to supplement, not
t
outcomes, deletions of outcomes, interventions,
replace, pharmacological interventions.”
ss
continuations of interventions)
(APS, 2009)
hi
Select the top priority nursing diagnosis and complete this nursing care plan.
V. NURSING DIAGNOSIS III. CLIENT DAY OF CARE OUTCOMES (2 to 3)
Acute Pain r/t abdominal surgery to remove hemo-dialysis catheter. A.Patient will use 1-10 number scale to identify current pain level and
establish a comfort-function goal
VI. DISCHARGE OUTCOME(S))
a
Patient will verbalize that they are pain free by rating pain as a 0/10 B.Patient will notify staff when pain level is greater than the
vi
by discharge. comfort-function goal.
Patient will perform activities of recovery or activities of daily living
easily. C. Patient will perform activities of daily living/recovery easily.
e d
IV. NURSING INTERVENTIONS SCIENTIFIC RATIONALE EVALUATION
Assess the client for pain presence routinely at “Pain assessment is as important as Day of Care Outcome(s)
ar
frequent intervals, often at the same time as physiological vital signs and pain is Met Unmet Partially Met
vital signs are taken, and during activity and considered as the “fifth vital sign” (APS, Documentation: (State behaviors that patient exhibited
sh
rest. Also assess pain with interventions or 2008) “Acute pain should be reliably that helped you determine that day of care outcome(s)
procedures likely to cause pain. assessed both at rest(important for were met. Also discuss interventions implemented to
Ask the client to identify a comfort-function goal, comfort) and during movement reach day of care outcome(s).
a pain level, on a self-report pain tool, that will (important for function and decreased Patient verbalized when they had pain and rated on a scale of
as
allow the client to perform necessary or client risk for cardiopulmonary and 1-10, they notified staff in a timely matter. Patient performed
desired activities easily. This goal will provide thromboembolic events.” (Breivik et al, ADL's well, but still unsteady.
2008) pg 601-602
w
the basis to determine effectiveness of pain
management interventions. If the client s “The relationship between pain level and
unable to provide a self-report, it will not be functional goals should be major focus
possible to establish a comfort-function goal. of the development of individualized
m e
Administer supplemental opioid doses as pain management plans” (Pasero &
ordered to keep the client's pain level at or
below the comfort-function goal, or desired
co rc McCaffery, 2004b) “Effective pain relief
with function such as mobilization,
coughing, and deep breathing is critical
Discharge outcome(s)
Met Unmet Partially Met
Documentation: (State behaviors that patient exhibited
o. ou
outcome if the client is unable to provide a
self-report based on clinical judgment or for decreasing risk factors for that helped you determine that discharge outcome(s) met.
behaviors. cardiopulmonary and thromboembolic Also discuss interventions implemented to reach
complications after surgery” (Breivik et discharge outcome(s).
Teach and implement non-pharmacological
er res
al, 2008) “Immobilization also is a major WAS NOT THERE WHEN PATIENT WAS DISCHARGED
interventions when pain is relatively well-
risk factor for chronic hyperalgesic pain FROM HOSPITAL, MAKING ME UNAWARE OF RESULTS.
controlled with pharmacological interventions.
after surgery” (Stubhaug&Breivik, 2007) RESULTS UNKNOWN.
“An order for prn supplementary opioid
eH y
doses available to provide appropriate
pain relief” (Pasero, Manworren, &
rs ud
McCaffery 2007; APS, 2008)
All interventions/rationale from Nursing Diagnosis “Non-pharmacological interventions
Plan Updates: (Include new interventions, change in
Handbook. Ackley, Ladwig. Pgs 323-328 should be used to supplement, not
t
outcomes, deletions of outcomes, interventions,
replace, pharmacological interventions.”
ss
continuations of interventions)
(APS, 2009)
hi
