Assessment
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Nursing DX/Clinical Problem
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Client Goals/Desired Outcomes/Objectives
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Nursing Interventions/Actions/Orders
and Rationale
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*I
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Evaluation
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Subjective:
Patient talks
about pressure ulcer during conversation and states that he is in pain when he doesn’t
have pain medication. Upon initial assessment patient experienced a 3 on pain scale.
Objective: Inability to
perform complete ADL’s. Patient seems
anxious about wound and shows some diaphoreses. Inability to sleef comfortably on
back side.
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Problem
Acute Pain
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Long Term:
Client will report
that pain management regimen relieves pain to satisfactory level with acceptable
and manageable side effects by discharge.
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Determine the client's current medication
use. Obtain a complete history of medications the
client is taking or has taken to help prevent drug-drug interactions and toxicity
problems that can occur when incompatible drugs are combined or when allergies are
present. The history also provides the clinician an understanding of what medications
have been tried and were or were not effective in treating the client's pain
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Client reports that pian
is relieved through pain medication which is the management regimen.
Goal met.
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Obtained client current
medication list from the MAR on [date]
at 1130.
See atached list for current medications.
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R/T
Tissue destruction
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Short Term:
Client will us
the pain rating scale to identify current pain and intensity of a 3 on a scale of
0-10 and determine comfort/function by end of shift on [date]
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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
).
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 scales is often determined
by the nurse's personal attitude about its effectiveness - Davidhizar, 2006.
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Client used the pain rating
scale of 0-10 to report pain. Patient reported a 1 on pain scale of 0-10. Goal met.
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[date]
1130 Assessed
patient using 0-10 pain rating scale and explained that 0 is no pain and 10 is the
worst pain.
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