Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective:

Patient talks about pressure ulcer during conversation and states that he is in pain when he doesn’t have pain medication. Upon initial assessment patient experienced a 3 on pain scale.

Objective: Inability to perform complete ADL’s.  Patient seems anxious about wound and shows some diaphoreses. Inability to sleef comfortably on back side.

Problem

Acute Pain

Long Term:

Client will report that pain management regimen relieves pain to satisfactory level with acceptable and manageable side effects by discharge.

Determine the client's current medication use. Obtain a complete history of medications the client is taking or has taken to help prevent drug-drug interactions and toxicity problems that can occur when incompatible drugs are combined or when allergies are present. The history also provides the clinician an understanding of what medications have been tried and were or were not effective in treating the client's pain (APS, 2004).

Client reports that pian is relieved through pain medication which is the management regimen.  Goal met.

Obtained client current medication list from the MAR on [date] at 1130.  See atached list for current medications.

R/T

Tissue destruction

Short Term:

Client will us the pain rating scale to identify current pain and intensity of a 3 on a scale of 0-10 and determine comfort/function by end of shift on [date]

Assess pain in a client by using a self-report such as the 0 to 10 numerical pain rating scale, Wong-Baker FACES Scale, or the Faces Pain Scale (see Pain: Assessment Guide and Appendix D). Systematic ongoing assessment and documentation provide direction for the pain treatment plan; adjustments are based on the client's response (Berry et al, 2006). EB: Single-item ratings of pain intensity are valid and reliable as measures of pain intensity (Jensen, 2003). EBN: An investigation of nursing attitudes and beliefs about pain assessment revealed that effective use of pain rating scales is often determined by the nurse's personal attitude about its effectiveness (Layman Young, Horton & Davidhizar, 2006).

Client used the pain rating scale of 0-10 to report pain. Patient reported a 1 on pain scale of 0-10. Goal met.

[date] 1130 Assessed patient using 0-10 pain rating scale and explained that 0 is no pain and 10 is the worst pain.

AEB

Stage 3 pressure ulcer on coccyx with tunneling. Size is 6cm by 5 cm.