NURSING CARE PLAN
Select the top priority nursing diagnosis and complete this nursing care
plan.
V. NURSING DIAGNOSIS
This study resource was
Acute Pain r/t abdominal surgery to remove hemo-dialysis
catheter.
A.
III. CLIENT DAY OF CARE OUTCOMES (2 to 3)
Patient will use 1-10 number scale to identify current pain
level and establish a comfort-function goal
shared via
VI. DISCHARGE OUTCOME(S)) B.Patient will notify staff when pain level is greater
Patient will verbalize that they are pain free by rating pain than the comfort-function goal.
as a 0/10 by discharge.
Patient will perform activities of recovery or activities of daily C. Patient will perform activities of daily living/recovery
living easily. easily.
IV. NURSING INTERVENTIONS SCIENTIFIC RATIONALE EVALUATION
• Assess the client for pain presence • “Pain assessment is as important Day of Care Outcome(s)
routinely at frequent intervals, often at as physiological vital signs and Met Unmet Partially Met
the same time as vital signs are taken, pain is considered as the “fifth Documentation: (State behaviors that patient exhibited
and during activity and rest. Also vital sign” (APS, 2008) “Acute pain that helped you determine that day of care outcome(s)
assess pain with interventions or should be reliably assessed both were met. Also discuss interventions implemented to
procedures likely to cause pain. at rest(important for comfort) and reach day of care outcome(s).
• Ask the client to identify a comfort- during movement (important for Patient verbalized when they had pain and rated on a
function goal, a pain level, on a self- function and decreased client risk scale of 1-10, they notified staff in a timely matter.
report pain tool, that will allow the for cardiopulmonary and Patient performed ADL's well, but still unsteady.
client to perform necessary or desired thromboembolic events.” (Breivik
activities easily. This goal will provide et al, 2008) pg 601-602
the basis to determine effectiveness of • “The relationship between pain
pain management interventions. If the level and functional goals should
client s unable to provide a self-report, be major focus of the development
ourseHero.
it will not be possible to establish a of individualized pain Discharge outcome(s)
comfort-function goal. management plans” (Pasero & Met Unmet Partially Met
McCaffery, 2004b) “Effective pain Documentation: (State behaviors that patient exhibited
• Administer supplemental opioid doses
relief with function such as that helped you determine that discharge outcome(s) met.
as ordered to keep the client's pain
mobilization, coughing, and deep Also discuss interventions implemented to reach
level at or below the comfort-
discharge outcome(s).
com
function goal, or desired outcome if breathing is critical for decreasing
risk factors for cardiopulmonary WAS NOT THERE WHEN PATIENT WAS DISCHARGED
the client is unable to provide a self-
and thromboembolic FROM HOSPITAL, MAKING ME UNAWARE OF RESULTS.
report based on clinical judgment or
complications after surgery” RESULTS UNKNOWN.
behaviors.
• Teach and implement non- (Breivik et al, 2008)
pharmacological interventions when “Immobilization also is a major risk
pain is relatively well- controlled with factor for chronic hyperalgesic
pharmacological interventions. pain after surgery”
(Stubhaug&Breivik, 2007)
Plan Updates: (Include new interventions, change in
• “An order for prn supplementary
outcomes, deletions of outcomes, interventions,
opioid
continuations of interventions)
doses available to provide
appropriate pain relief” (Pasero,
Select the top priority nursing diagnosis and complete this nursing care
plan.
V. NURSING DIAGNOSIS
This study resource was
Acute Pain r/t abdominal surgery to remove hemo-dialysis
catheter.
A.
III. CLIENT DAY OF CARE OUTCOMES (2 to 3)
Patient will use 1-10 number scale to identify current pain
level and establish a comfort-function goal
shared via
VI. DISCHARGE OUTCOME(S)) B.Patient will notify staff when pain level is greater
Patient will verbalize that they are pain free by rating pain than the comfort-function goal.
as a 0/10 by discharge.
Patient will perform activities of recovery or activities of daily C. Patient will perform activities of daily living/recovery
living easily. easily.
IV. NURSING INTERVENTIONS SCIENTIFIC RATIONALE EVALUATION
• Assess the client for pain presence • “Pain assessment is as important Day of Care Outcome(s)
routinely at frequent intervals, often at as physiological vital signs and Met Unmet Partially Met
the same time as vital signs are taken, pain is considered as the “fifth Documentation: (State behaviors that patient exhibited
and during activity and rest. Also vital sign” (APS, 2008) “Acute pain that helped you determine that day of care outcome(s)
assess pain with interventions or should be reliably assessed both were met. Also discuss interventions implemented to
procedures likely to cause pain. at rest(important for comfort) and reach day of care outcome(s).
• Ask the client to identify a comfort- during movement (important for Patient verbalized when they had pain and rated on a
function goal, a pain level, on a self- function and decreased client risk scale of 1-10, they notified staff in a timely matter.
report pain tool, that will allow the for cardiopulmonary and Patient performed ADL's well, but still unsteady.
client to perform necessary or desired thromboembolic events.” (Breivik
activities easily. This goal will provide et al, 2008) pg 601-602
the basis to determine effectiveness of • “The relationship between pain
pain management interventions. If the level and functional goals should
client s unable to provide a self-report, be major focus of the development
ourseHero.
it will not be possible to establish a of individualized pain Discharge outcome(s)
comfort-function goal. management plans” (Pasero & Met Unmet Partially Met
McCaffery, 2004b) “Effective pain Documentation: (State behaviors that patient exhibited
• Administer supplemental opioid doses
relief with function such as that helped you determine that discharge outcome(s) met.
as ordered to keep the client's pain
mobilization, coughing, and deep Also discuss interventions implemented to reach
level at or below the comfort-
discharge outcome(s).
com
function goal, or desired outcome if breathing is critical for decreasing
risk factors for cardiopulmonary WAS NOT THERE WHEN PATIENT WAS DISCHARGED
the client is unable to provide a self-
and thromboembolic FROM HOSPITAL, MAKING ME UNAWARE OF RESULTS.
report based on clinical judgment or
complications after surgery” RESULTS UNKNOWN.
behaviors.
• Teach and implement non- (Breivik et al, 2008)
pharmacological interventions when “Immobilization also is a major risk
pain is relatively well- controlled with factor for chronic hyperalgesic
pharmacological interventions. pain after surgery”
(Stubhaug&Breivik, 2007)
Plan Updates: (Include new interventions, change in
• “An order for prn supplementary
outcomes, deletions of outcomes, interventions,
opioid
continuations of interventions)
doses available to provide
appropriate pain relief” (Pasero,
