SUPPORTIVE DATA ----------------------------
Subjective: Pt states “my pain is still at 8/10, is my medication working?”
Objective: 1. DX-UTI & possible urosepsis, Hip Fracture and fall during not a candidate for surgery, CHF
2.Buck’s traction applied
3. Assessment: Limited mobility, SOB, confusion, does not want to get out of bed due to pain & fear of falling,
4. Meds: Hydrocodone 7.5 mg/acetaminophen 325mg 1 to 2 tab PO, PRN for pain Tylenol 650 mg 2 PO, PRN for pain | NURSING DIAGNOSIS ------------------------------
Knowledge deficit for pain management r/t lack of follow up with instructions | PATIENT GOALS/OUTCOME CRITERIA --------------------------------
Patient will have knowledge of pain mgmt
A.E.B: Stg: 1. Verbalizes use and dosing of pain medication
2. Verbalizes pain relief lover than 4/10 in 30-60 min after intervention
3. Demonstrates use of non medication pain mgmt solutions by end of shift
Ltg: 1. Verbalizes how often can get pain medications
2. Verbalizes ability to do ADL with pain below 6/10 by D/C | NURSING ACTIONS 1. Assess knowledge of current pain medications/does/time/use
2. Instruct on how often to take pain medications
3. Instruct of pain meds if pain level is above 4/10
4.Teach reason for keeping pain below 4/10
5.Instruct on taking Tylenol 650 mg before activity/ADL
6.Teach on different strategies for pain relief including positioning, activity, imagery
7.Instruct on schedule for all pain meds in hospital and on D/C OBSERVATIONS/ CONCLUSIONS 0800-patient not accepting