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Subjective
Patient complained of pain.
Requested pain medications
Objective
Grimacing.
Guarding.
Patient rates pain 10/10.
Decreased movement due to area of surgery.
Post-surgery discomfort.
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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
Scrotal debridement and closure
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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 non-pharmacological methods to help control pain by
the end of the shift.
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1.
Assess pain rating during initial shift assessment, every 4 hours,
and as needed by using the scale of 0-10 (0 being no pain and 10 being the worst
possible pain) and having the patient describe location, onset, duration, and character
of the pain because it can help guide the treatment plan for the patient by getting
all the information about the pain possible (Ackley & Ladwig, 2008, p 604).
2.
Administer prn pain medications to help control the severe pain (Ackley
& Ladwig, 2008, p 605).
3.
Teach patient to use non-pharmacological techniques (such as distraction
by TV and soft soothing music) when pain is relatively controlled because it can
get their mind off the pain and 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 non-pharmacological treatments by using distraction and soothing music, in addition
to pain medication, to keep pain in controlled level. Patient demonstrated use of
these methods before pain medications were given.
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Continue to assess pain every 4 hours and as needed to keep pain at a controlled
level.
Continue to assess pain frequently and keep pain at a rate of 2/10.
Reinforce teaching and encourage use of non-pharmacological treatments as needed
to control pain and before the use of analgesic medications.
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