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