3/1/2015

NursingCarePlanforAcutePain

NursingCarePlan

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MedicalDiagnoses:AcutePain
Assessment

Subjective

Patient
complainedof
painandasked
forpain
medicinebefore
morning
assessment.

Objective

Grimacing.

Ptplacing
handon
abdomen,
guarding.

Patientrates
pain8/10

Nursing
DX/Clinical
Problem
Problem

Acutepain

R/T

irritated
mucosafrom
acid
secretions

AEB

grimacing,
patient
statedpain
levelof8/10

ClientGoals/Desired
Outcomes/Objectives

Nursing
Interventions/Actions/Orders
andRationale

*I

LongTerm:

Patientwillratepainasa
2/10orlessatthetimeof
dischargeandwillbesent
homeonlowdoseoralpain
medications.

Assesspainlevelevery4
hoursbecauseitcan
providedirectionforpain
treatmentplanand
adjustmentscanbemade
clientsresponse(Ackley
&Ladwig,2008,p604).

ShortTerm:

1. Patientwillrate
painasa2/10orless
attheendofthe
shift.

2. Patientwill
demonstratehowto
use
nonpharmacological
methodstohelp
controlpain.

1. Administerprnpain
medicationstohelp
controlthesevere
pain(Ackley&
Ladwig,2008,p
605).
2. Teachpatienttouse
nonpharmacological
treamtmentswhen
painisrelatively
controlledbecause
distractionandother
methodsshouldbe
usedtosupplement
painmedications
(Ackley&Ladwig,
2008,p605).

Evaluation
Goals

Interventions

Goalstillinprogress.
Patienthasrelatively
controlledpainevery4
hourshoweverstillusing
IVmedications.

Continueto
assesspainevery
4hoursand
decreaseamount
ofIVmedications
usedifpossible.

Goalmet.Patient
statedpainasa0/10
aftergivenIVpain
medication.

Goalmet.Patient
understandstheuse
of
nonpharmacological
treatmentsin
additiontopain
medicationtokeep
painincontrolled
level.

Continueto
assesspain
every4hours
andeverytime
enteringthe
roomtokeep
painata
controlled
level.

Continueto
assespain
frequentlyand
keeppainata
rateof2/10.

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*I=Implementation.Checkthoseinterventions/actions/ordersthatwereimplemented.

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