Nursing Care Plan

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Medical Diagnoses: Acute pain, Physical and biological injury agents and advanced disease process.

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

Subjective:

Client expressed pain that was “aching and constant.” As well as a headache and her “hands are cramping.”

Hx of DM II, CAD

   

Objective:

Temp:  101.0

Basilar rales bilaterally

Elevated BP (145/86)

Elevated HR (110)

Client is in atrial fibrillation w/ rapid ventricular response

EKG findings of inferior infarction and left axis deviation

Decreased grips/weakness on left side

Decreased urine output (0 ml/10 hours)

Elevated potassium level of 5.3

Elevated BUN (41)

Elevated Creatinine (1.73)

2x3, 1 inch depth stage II ulceration on coccyx

Unstageable ulceration on right heal

Presence of multiple tears on upper extremities

Client is NPO

Elevated blood glucose (185)

Post-CVA

Problem

Acute pain

Long Term:

Client will function on acceptable ability level with minimal interference from pain and medication side effects by [date], 16:00.

   


Tell the client to report pain location, intensity, and quality when experiencing pain.  Assess and document the intensity of pain with each new report of pain and at regular intervals.  Systematic, ongoing assessment and documentation provide direction for the pain treatment plan  (APS, 2003)

R/T

Physical and biological injury agents and advanced disease process.

 

Short Term:

Client will express relief from pain within 30 minutes of medication administration. 

   

--Assess current pain level.  The client’s self report is the single most reliable indicator of level of pain  (APS, 2004).

-Assess location of pain

-Administer medication as ordered

-Reassess pain level to ascertain relief level achieved

-Discuss with client past experiences with pain and effectiveness of medications and side effects.

-Discuss with client comfort-function pain level.  Attempt to keep client within that level to maintain functionality and ADLs .  The pain rating that allows a client to have appropriate function should be determined to allow a measurable method of outcomes of pain management  (Griffie, 2003).

 

AEB:

Pain rating of 6/10

Verbalization of “aching, constant pain”

Activity intolerance



 

References

   

Ackley, B. J., & Ladwig, G. B. (2008). Nursing Diagnosis Handbook. St. Louis: Elsevier.

Ayello, E.A., Braden B:  How and why to do pressure ulcer risk assessment, Advanced Skin Wound Care 15(3):  125, 2002.

Griffie, J. (2003). Pain Control: Addressing inadequate pain relief. American Journal of Nursing , 8 (103), 61-63.

Hinrichs, M., Huseboe, J., & Tang, J. H. (2001). Research-based protocol. Management of constipation. Journal of Geronological Nursing , 27 (2), 17.

Noble M, Voegeli D, Clough GF: A comparison of cutaneous vascular responses to transient pressure loading in smokers and nonsmokers, J Rehabil Res Dev 40(3):283288, 2003.

Pender NJ, Murdaugh CL, Parsons MA: Health promotion in nursing practice, ed 5, Upper Saddle River, NJ , 2006, Pearson Prentice Hall.

Russell L: The importance of patients' nutritional status in wound healing, Br J Nurs 10(6):542, 544549, 2001.

Schols, A. M., Soeters, P. B., & Mostert, R. et al. (1995). Physiologic effects of nutritional support and anabolic steroids in patients with chronic obstructive pulmonary disease. A placebo-controlled randomized trial. American Journal of Respiratory Critical Care Medicine , 152 (4), 1268-1274.

Simmons, P., & Simmons, M. (2004). Informed Nursing Practice: The Administration of Oxygen to Patients with COPD. MedSurg Nursing , 13 (2), 82-85.

Society, A. P. (2003). American Pain Society: Principles of analgesic use in the treatment of acute pain and cancer pain. Glenville, IL : American Pain Society.

Speelberg, B., & Van Beers, F. et al. (2003). Artificial ventilation in the semi-recumbent position imrpoves oxygenation and gas exchange. Chest , 124 (4), 203S.

Tsoneva, J., & Shaw, J. (2004). Understanding patients' beliefs and goals in medicine-taking. Professional Nurse , 8 (16), 466-468.




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