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 complained of pain and asked for pain medicine
before morning assessment.
Objective
Grimacing.
Pt placing hand on abdomen, guarding.
Patient rates pain 8/10
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Problem
Acute pain
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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.
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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).
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Goal still in progress. Patient
has relatively controlled pain every 4 hours however still using IV medications.
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Continue to assess pain every
4 hours and decrease amount of IV medications used if possible.
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R/T
irritated mucosa from acid secretions
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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.
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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).
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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.
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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.
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