?? about Care plan/ Fun Clinical today!

[kwagner_51]

I have been at the hospital for the last 3 Mondays. On the 1st Monday I had an 80 y/o male who was going home before my clinical ended at noon. Last week I was with another student and we did care together on a 67y/o thyroidectomy patient. It was cool, but I didn't get to do much!

Today, I was assigned to a 23 y/o who wrecked his 4 wheeler. He had alot of pain and had a huge bruise on his outer Right Thigh. He also broke his left clavicle. I got to do total care!! He got a total bed bath, except for his privates, which he washed himself. [Although he wasn't very private about it!! : imbar ] He couldn't walk b/c of the pain, but was able to move to the chair w/assistance.

Now I have to write my first care plan and I am SCARED!! This is what I am thinking of putting for the P.E.S. :

Acute Pain, r/t blunt trauma AEB moaning and the inability to walk.

What do you think? Is that a good diagnosis?

[PSA, RN]

Sounds like you had a good day with your pt. Here is one of my old ncp that I have on pain. It needs to be tailored to your pt. but maybe it will give you an idea.

Chronic pain r/t actual tissue damage secondary to surgery AEB guarding and patient statement of pain "5" on a scale of 1-10.

My short term goal: The patient will report that the pain management regimen relieves pain level by a decrease to 3 on a scale of 1-10 AEB patient statement.

My nursing interventions:

1. Tell client to report location, intensity (using a pain rating scale), and quality when experiencing pain.

2. When opioids are administered, assess, pain intensity, sedation, and respiratory status at regular intervals.

3. Monitor and record vital signs q 4 hr.

4. Plan care activities around periods of greatest comfort whenever possible.

I also have the documented rationale's for those interventions. If you would like to see those to just let me know.

Sorry this was so long. I hope this helps in some way. They should always be tailored to your patient but maybe this will give you an idea to start with.

Good Luck

[kwagner_51]

THANK YOU sooooooo much!!! If I pass this care plan with at least an 80% I won't have to worry about the other 3 we have to write. I want to suceed so bad I can taste it!!

This will HELP alot!!!

[PSA, RN]

If you need any more help let me know. I am now trying to find my old NCP's to see if there are any more. But since I have been out of school a while I have got to go digging for them.

Take Care

[icesk8ie]

When I write a pain diagnosis it goes something like this:

Acute pain R/T tissue trauma secondary to car accident AEB rating pain scale 5/10 and guarding.

Goal: Pt. will relate effective pain relief 30 minutes after administration of pain medication

Interventions:

1. Adminster ordered pain meds as ordered.

2. Check 30 minutes after pain med administration to assess effectiveness.

3. Teach deep breathing and relaxation techiniques.

Hope that helps!