Sample Pain Care Plan
Nursing Care Plan
Client name: Mrs. Chan Age/ sex: 48/F Medical diagnosis: Fluid overload, decreased TK output and decreased Hb Assessment date: 25-11-2012 Diagnostic statement (PES): Excess fluid volume related to compromised regulatory mechanism secondary to end-stage renal failure as evidence by peripheral edema and patient’s weight gained from 69.8kg to 73.6kg within 4 days.
Assessment
Nursing Diagnosis
Goals & Expected Outcomes
Nursing Interventions
Rationales
Methods of Evaluation
Subjective data:
1. The client claimed her weight started to gain quickly 2 weeks before admission.
2. The client reported of taut and shiny skin appeared on the limbs and face.
3. The client complained …show more content…
Expected outcomes:
1. The client will be able to state cause of the pain by 3/12/2012
2. The client will be able to verbalize the changes of the pain level after giving the pain treatment by 3/12/2012.
3. The client will be able to demonstrate two methods to relieve pain by 3/12/2012.
1. Ongoing assessments
a) Assess pain characteristics including quality, severity, anatomical location, onset, duration, aggravating factors.
b) Assess client’s perception of the effectiveness of methods used for pain relief in the past.
c) Assess the client's pain level before and after pain treatment by using pain scale
2. Therapeutic interventions
a) Consult with doctor to provide pain killer.
b) Heat application but no more than 20min/hr
c) Promote optimal mobility by exercise program.
3. Education for client and caregivers
a) Educate the cause of the pain and sciatica.
b) Determine with client and caregiver the effects of chronic pain on the person’s …show more content…
(Gulamick & Myers, 2007)
b) Client with chronic pain has a history of using many pharmacological and nonpharmacological methods to control pain. (Gulamick & Myers, 2007)
c)Monitoring the effectiveness of the treatments given.( Wild Iris Medical Education,2010)
2a) Non-steroidal anti-inflammatory drugs or oral steroids can be helpful in reducing the inflammation which is usually a contributing factor in sciatica. (Margot , 2009)
b) Heat reduces pain through improved blood flow to the area and through reduction of pain reflexes.long lasting cause burns. (Gulamick & Myers, 2007)
c) Regular movement and exercise is necessary to nourish the various structures in the low back and encourage the strength needed to support the low back. (Margot , 2009)
3a) client with pain knowledge experience less stress. (Carpenito, L. J., 2010)
b) Pain affects quality of life and it helps family understand pain’s effects on role and relationships.(Ferrell, 1995)
1. Ask the client to demonstrate two pain relief methods.
2. Ask the client to state cause of the pain and sciatica.
3. Ask the client to verbalize the scale of pain before and after the
Client name: Mrs. Chan Age/ sex: 48/F Medical diagnosis: Fluid overload, decreased TK output and decreased Hb Assessment date: 25-11-2012 Diagnostic statement (PES): Excess fluid volume related to compromised regulatory mechanism secondary to end-stage renal failure as evidence by peripheral edema and patient’s weight gained from 69.8kg to 73.6kg within 4 days.
Assessment
Nursing Diagnosis
Goals & Expected Outcomes
Nursing Interventions
Rationales
Methods of Evaluation
Subjective data:
1. The client claimed her weight started to gain quickly 2 weeks before admission.
2. The client reported of taut and shiny skin appeared on the limbs and face.
3. The client complained …show more content…
Expected outcomes:
1. The client will be able to state cause of the pain by 3/12/2012
2. The client will be able to verbalize the changes of the pain level after giving the pain treatment by 3/12/2012.
3. The client will be able to demonstrate two methods to relieve pain by 3/12/2012.
1. Ongoing assessments
a) Assess pain characteristics including quality, severity, anatomical location, onset, duration, aggravating factors.
b) Assess client’s perception of the effectiveness of methods used for pain relief in the past.
c) Assess the client's pain level before and after pain treatment by using pain scale
2. Therapeutic interventions
a) Consult with doctor to provide pain killer.
b) Heat application but no more than 20min/hr
c) Promote optimal mobility by exercise program.
3. Education for client and caregivers
a) Educate the cause of the pain and sciatica.
b) Determine with client and caregiver the effects of chronic pain on the person’s …show more content…
(Gulamick & Myers, 2007)
b) Client with chronic pain has a history of using many pharmacological and nonpharmacological methods to control pain. (Gulamick & Myers, 2007)
c)Monitoring the effectiveness of the treatments given.( Wild Iris Medical Education,2010)
2a) Non-steroidal anti-inflammatory drugs or oral steroids can be helpful in reducing the inflammation which is usually a contributing factor in sciatica. (Margot , 2009)
b) Heat reduces pain through improved blood flow to the area and through reduction of pain reflexes.long lasting cause burns. (Gulamick & Myers, 2007)
c) Regular movement and exercise is necessary to nourish the various structures in the low back and encourage the strength needed to support the low back. (Margot , 2009)
3a) client with pain knowledge experience less stress. (Carpenito, L. J., 2010)
b) Pain affects quality of life and it helps family understand pain’s effects on role and relationships.(Ferrell, 1995)
1. Ask the client to demonstrate two pain relief methods.
2. Ask the client to state cause of the pain and sciatica.
3. Ask the client to verbalize the scale of pain before and after the