Medical Diagnoses: Acute Pain , UTI diagnosis

Assessment Nursing DX/Clinical Problem Problem Acute Pain Client Goals/Desired Outcomes/Objectives Long Term: Pt will verbalize understanding of pain management plan by discharge. Nursing Interventions/Actions/Orders and Rationale *Educate the pt on the importance of taking medications to keep pain under control. Rationale: Teaching the patient to stay on top of their pain and prevent it from getting out of control improves the ability to accomplish the goals of recovery. (Ackley & Ladwig, 2008, p. 610) * Develop a treatment plan with the pt. Rationale: Client input into the plan of care improves the likelihood of successful management. *Educate the pt on nonpharmacological approaches for pain control. Rationale: Nonpharmacological interventions are used to complement, not replace, pharmacological interventions. (Ackley & Ladwig, 2008, p. 610) *Assess pain by using the 10 point pain rating scale q4 hrs *I Goals Pt goal met. Pt was able to verbalize her understanding of her pain management plan to the staff. Pt was able to explain to the staff the measures she was taught to effectively control her pain. Pt comprehends the needed measures to control her pain at home. Pt stated that she thinks she can control her pain levels by herself at home now. Evaluation Interventions Continue interventions as listed. Continue to educate the pt on the importance of taking her medications to control her pain. Continue to assist in developing a thorough treatment plan with the pt. Continue to reinforce the importance of using nonpharmacological measures to control pain.

Subjective Pt states that she is in pain in her private area.

Objective Pt states her pain level is 7 out of 10 on the pain scale. Insertion of foley catheter Diagnosis of UTI Pt demonstrates grimaces and guarding

R/T

Short Term: Pt will report a

Goal met. Pt reported a decrease in her pain

Continue interventions as listed. Continue to

UTI diagnosis

decrease in her pain level or <4 out of 10 on this shift.

or PRN. Rationale: Single item ratings of pain intensity are valid and reliable as measures of pain intensity. Systematic ongoing assessment and documentation provide direction for the pain treatment plan; adjustments are made based on the clients response. (Ackley & Ladwig, 2008, p.604) *Administer medications as ordered. Rationale: Pharmacological interventions are the cornerstone of management of moderate to severe pain. Unless contraindicated, all clients with acute pain should receive a nonopiod agent around the clock. (Ackley & Ladwig, 2008, p.605) *Explain to the pt the pain management approach that has been ordered. Rationale: One of the most important steps toward improved control of pain is a better client understanding of the nature of pain, its treatment, and the role the client needs to play in pain control. (Ackley & Ladwig,

AEB Pt complaints of perineal soreness and pain Pt demonstrates grimaces and guarding Pt rates pain at a 7 on a 10 point pain scale. UTI diagnosis

level that was originally 7 out of 10. Pt was given appropriate medications to relieve the pain. She did not report an increase in pain throughout the day and reported 2 out of 10 by the end of the shift.

evaluate the pts pain rating using the 10 point pain scale q 4 hrs or PRN. Continue to administer medications as ordered. Continue to reinforce and educate the pt on the pain management she is receiving.

2008, p.606)