My name is Austin, I'm a student nurse in NH. I'm trying to write my goals page for postpartum pain from a c-section incision. I'm still learning how to write a long term goal and a short term goal... The goals must be singular, specific, and measurable with a definite time limit. I have my nursing diagnosis, long and short term goals but am having trouble coming up with assessments, interventions, teaching and advocacy.
Nursing Diagnosis: Acute pain related to injuring agent (physical; from surgical incision) manifested by patient complaint of pain rated 5/10.
Long term goal: 4/7/09 0700 The patient will rate pain as less than or equal to 3/10 through discharge.
Short term goal: 4/7/09 0700 The patient will ask pain medication before pain reaches or exceeds pain rating of 3/10.
Assess location, intensity(on pain scale of 0-10), duration, pain type [every 4 hours and as needed]
Provide other comfort measures such as ice/cold pack to apply to area of discomfort. [as needed]
Assist patient into different positions to help with pain relief [as needed]
Administer pain medication as ordered
Reassess pain within 1 hour of administering pain medication to see if patient needs more medication or alternative therapy [one hour after administering pain medication]
Teach patient to report any changes in the location, intensity, or type of pain [teach when giving first dose of pain medication]
Teach patient to ask for next dose of medication before pain escalates too much. Teach patient that it is easier to keep pain down if medication is taken before it escalates. Teach this to patient with first dose of pain medication.
Advocate additional medication if patient is not comfortable even when highest doses of medications are given [when patient reports pain level of greater than 3/10 during medication peak]
What do you think? I can't come up with anything else. I left out the interventions the instructor didn't like or thought weren't applicable.
I have to resubmit tomorrow, any suggestions will help.
--Austin from NH
Apr 17, '09
Some other goals and interventions that I can think of are helping her turn around in bed, possibly using a pillow for support, taking a shower, and possibly needing help to go to the bathroom. Also taking a pillow for a mom to hold around her waist while she walks will help her feel like the insides aren't coming out. Post partum women might be afraid to have a BM after delivery and she may need steps and education to help guide her on that. Another goal could also be about the mechanics of breastfeeding and what positions may help her successfully hold the baby without pain from the incision. For example, the football hold or a cross cradle hold.
Apr 17, '09
Honestly I think this looks very thorough. We aren't required to go into nearly as much detail, down to dates and all, as this!!
Apr 17, '09
post #157 of this thread CAREPLANS HELP PLEASE! (with the R\T and AEB)
on allnurses has specific information on how to write goal statements.
your goals must be a prediction of what will happen as a result of those interventions having been performed. so, there must be linkage between them. this student thread has interventions for pain that you should look at: http://allnurses.com/nursing-student...al-376731.html
- nrsg dx for total hip replacement.
use the guidelines on post #157 above to write your goal statements based on your interventions.
on the student forums is information on care planning: http://allnurses.com/general-nursing...ns-286986.html
- help with care plans
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