Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

Patient complained of pain and asked for pain medicine before morning assessment.

Objective

Grimacing.

Pt placing hand on abdomen, guarding.

Patient rates pain 8/10

Problem

Acute pain

Long Term:

Patient will rate pain as a 2/10 or less at the time of discharge and will be sent home on low dose oral pain medications.

Assess pain level every 4 hours because it can provide direction for pain treatment plan and adjustments can be made client’s response (Ackley & Ladwig, 2008, p 604).

Goal still in progress. Patient has relatively controlled pain every 4 hours however still using IV medications.

Continue to assess pain every 4 hours and decrease amount of IV medications used if possible.

R/T

irritated mucosa from acid secretions

Short Term:

1.        Patient will rate pain as a 2/10 or less at the end of the shift.

2.        Patient will demonstrate how to use nonpharmacological methods to help control pain.

1.      Administer prn pain medications to help control the severe pain (Ackley & Ladwig, 2008, p 605).

2.      Teach patient to use nonpharmacological treamtments when painis relatively controlled because distraction and other methods should be used to supplement pain medications (Ackley & Ladwig, 2008, p 605).

Goal met.  Patient stated pain as a 0/10 after given IV pain medication.

Goal met.  Patient understands the use of nonpharmacological treatments in addition to pain medication to keep pain in controlled level.

Continue to assess pain every 4 hours and everytime entering the room to keep pain at a controlled level.

Continue to asses pain frequently and keep pain at a rate of 2/10.