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:
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.
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Problem
Acute Pain
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Long Term:
Client will report that
pain management regimen relieves pain to satisfactory level with acceptable and
manageable side effects by discharge.
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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).
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Client reports that pian is relieved through pain medication which is the management
regimen. Goal met.
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Obtained client current medication list from the MAR on [date] at 1130.
See atached list for current medications.
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R/T
Tissue destruction
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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]
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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).
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Client used the pain rating scale of 0-10 to report pain. Patient reported a 1 on
pain scale of 0-10. Goal met.
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[date] 1130 Assessed patient using 0-10 pain rating scale and explained that 0
is no pain and 10 is the worst pain.
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