Nursing Care Plan for Pain

Some Care Plans
April 30, 2016 – 02:51 am

Nursing Care Plan : Acute pain Nursing Care Plan : Acute pain related to ischemia of myocardial

Don’t copy these guys! They are plans I used in school and certainly haven’t been review by a group of peers or experts. Use as an example to do your own or to get ideas from:

See Tired Studen Nurse webblog for much more and better care plans:

Patient: SC
Nursing Diagnosis: Acute Pain r/t recent surgical procedure as evidenced by patient’s agitation, patient stating pain at 3 on a 0-10 pain scale, patient constantly clearing throat, and patient stating her throat was sore and dry.
Goals Interventions Evaluation
Short-term goal: Patient will have pain at less than a 3 within thirty minutes. 1. Administer morphine 2mg/ml, IV push, as prescribed, immediately (10:15). Goal met: Patient stated that pain was at a 2 on a 0-10 pain scale at 10:45.
2. Provide patient with pillows in chair for proper alignment and quiet atmosphere to allow for pain medication to take effect after administering medication. Goal met: Patient resting quietly, properly aligned within 10 minutes of pain medication.
3. Have patient suck on hard candy to relieve hoarseness and dry throat. Goal met: Patient used hard candy and reported relief of dryness and some improvement of hoarseness.
Long-term goal: Patient will maintain a pain level of 3 or less during remaining of hospital stay. 1. Instruct patient to request pain medication as needed and before pain is at level 3 on a 0-10 pain scale. Goal met: Patient stated understanding that she should ask for pain medication as described.
2. Assess pain level every 2 hours and administer pain medication as needed. Goal not met: Continue intervention.
3. Remind patient of hard candy or lozenges and voice rest should be practice for relief of throat dryness and hoarseness. Also provide humidification if problem persists. Goal partially met: Patient reminded of intervention. Documentation of problem should help nurses on succeeding shifts to continue or change intervention as needed.

Problem List (List problems as you observe them, then rank according to highest priority)

Rank Problem
Impaired Skin Integrity
Knowledge deficit – going home with Foley catheter
Disturbed Body Image – having to wear a Foley for 2 weeks
Develop a care plan based on the top two problems above.Nursing Diagnosis – Use PES format – (Based on the objective and subjective data from your worksheet)
Nursing Diagnosis (Problem) r/t Etiology (What caused the problem) AEB Symptoms (Evidence of the problem)Impaired Skin Integrity r/t surgical removal of prostate AEB three derma bonded incision sites and one right midline immediately post JP drain.
Expected Outcomes Interventions (with brief rationale) met not met
Interesting facts

Presbyterian Hospital Huntersville, a part of the Novant Health organization, is a private, 60-bed not-for-profit medical facility located in Huntersville, North Carolina.
Presbyterian Hospital Huntersville offers a variety of services including:
• Cancer services, including chemotherapy, support for stem cell transplant patients, blood product...

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