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
“My hip is hurting
from when I broke it.”
Objective:
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Problem
Chronic Pain
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Long Term:
Client will function with
minimal interference from pain, rated
as 3 or less on a scale o f 0-10 within 2 months.
Client will function with minimal interference from medication side within
one week..
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N/A
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The client will report
pain at less than three on a scale of
0-10.
Goal met, patient reported
pain level of 0.
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The nurse will help the
client by repositioning to avoid pressure on the healing hip, administer medications
as indicated by pain level and call physician to change medication if pain is unrelieved
by prior interventions.
Client reported no pain.
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R/T
Progression of joint deterioration, injury, surgical procedure, and chronic kidney
disease
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Short Term:
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N/A
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Client described past measures to handle pain and their effectiveness.
She described no history of side or adverse effects from previous methods
utilized.
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