Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

“My hip is hurting from when I broke it.”

Objective:

Client does not ambulate.

Problem

Chronic Pain

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..

Tell the client to report pain location, intensity and quality when experiencing pain.  Assess and document the intensity of the pain with each new report of pain and at regular intervals of every two hours.   Systematic ongoing assessment and documentation provide the direction for pain treatment plans ; adjustments are based on the client’s response. (Nursing Diagnosis Handbook, Ackley and Ladwig, pg. 613)

N/A

The client will report pain at less than three on a scale of  0-10.

Goal met, patient reported pain level of 0.

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.

R/T

Progression of joint deterioration, injury, surgical procedure, and chronic kidney disease

Short Term:

Use pain rating scale to identify current level of pain intensity, and determine comfort/function goal.

Teach client to use pain rating scale, applying a rating of 0-10.  Ask the client to describe past and current experiences with pain and the effectiveness of the methods used to manage the pain, including experiences with side effects, typical coping responses and the way the client expresses pain.  A study revealed that barriers can affect a client’s willingness to report pain and use analgesics.  Many harbored fears and misconceptions regarding the use of analgesics, management of side effects and risk of addiction.

N/A

Client utilized the pain rating scale and reported a level of 0.

Client described past measures to handle pain and their effectiveness.  She described no history of side or adverse effects from previous methods utilized.

AEB

as evidenced by patient self report of pain level.