You are the nurse caring for this patient. You must develop a care plan for ACUTE PAIN
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Directions:
You are the nurse caring for this patient. You must develop a care plan for ACUTE PAIN that includes the following:
· Problem identification
· Short term goal
· Long term goal
· 5 nursing interventions/actions with a rational for each intervention. State if the intervention is independent, interdependent or dependent. Make sure to have at least one of each for this assignment- all interventions should be in priority order. Remember ABC (airway, breathing, circulation) when prioritizing.
· Also discuss how you would evaluate the short term goal, long term goal, and interventions
Patient
Mr. Gordon, a 52 year-old client who was admitted to the med/surg unit following an MVC (motor vehicle crash). He suffered rib fractures and has a laceration along his right thigh.
Assessment:
|
Neuro |
A&O x3 |
|
Respiratory |
Lung sounds CTA (clear to auscultation) bilaterally |
|
Cardiac |
S1S2 auscultated |
|
GI |
Bowel sounds active in all 4 quadrants |
|
GU |
Voiding |
|
Skin |
Laceration noted to right thigh covered with bandage. No drainage noted. PWD (pink, warm, dry) |
|
Vital Signs |
BP 150/88 Pain: 9 on a 0 – 10 scale (0 being no pain, 10 being the worst)
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Care Plan Grading Rubric
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Topic |
Points Possible |
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Problem |
1 |
|
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Short term goal |
1 |
|
|
|
Short term evaluation (met or not and rational) |
1 |
|
|
|
Long term goal |
1 |
|
|
|
Long term evaluation (met or not and rational) |
1 |
|
|
|
Nursing interventions (5 total, appropriate for meeting goal) |
5 |
|
|
|
Nursing Rationales (5 total, appropriately related to intervention) |
5 |
|
|
|
Evaluation of Intervention effectiveness |
5 |
|
|
|
Total: |
20 |
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Problem identification: |
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Short Term goal: (need a measureable timeframe):
Evaluation of short-term goal: Was the goal met, partially met, or unmet? How do you know? What did you observe to come to this conclusion?
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Long-term goal: (needs a measureable time frame and will take longer to complete than the short term goal)
Evaluation of long- term goal: Was the goal met, partially met, or unmet? How do you know? What did you observe to come to this conclusion?
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Nursing Outcome Criteria: |
Nursing Outcome Criteria: List five nursing interventions and rationale for each. State if intervention is dependent (D), independent (I), or interdependent (ID). (Cite source for rationales): |
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1. Intervention: Rationale:
2. Intervention: Rationale:
3. Intervention: Rationale:
4. Intervention: Rationale:
5. Intervention: Rationale:
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