Nursing Care Plan
Nursing DX/Clinical Problem
Client Goals/Desired Outcomes/Objectives
Client expressed pain that was “aching and constant.”
As well as a headache and her “hands are cramping.”
Hx of DM II, CAD
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)
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)
Physical and biological injury agents and advanced disease
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
-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
Pain rating of 6/10
Verbalization of “aching, constant pain”
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