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Medical Diagnoses: Acute Pain, Scrotal debridement and Closure

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.

         

Requested pain medications

         

         

         

Objective

 

Grimacing.

 

Guarding.

 

Patient rates pain 10/10.

 

Decreased movement due to area of surgery.

 

Post-surgery discomfort.


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

Scrotal debridement and closure

      

      

      

      

      

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.

 

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).

 

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.

 

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.


AEB

      

Grimacing, guarding, decreased movement, and pain rated 10/10.


      

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*I = Implementation.  Check those interventions/actions/orders that were implemented.


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