Ok...these are my instructions...and my careplan. Trouble is...I have a hard time doing only 2 interventions! So which should I use? Also...I am unsure how to write goals. I keep getting dinged on that.
Directions
Read the following case study. After reading, complete a nursing care plan. Write the care plan on the form included in your syllabus. The nursing care plan needs to include major assessment cues, identification of the intra, inter, and extrapersonal stressors, the most relevant nursing diagnosis, one goal, one outcome criteria, and two nursing interventions including referenced rationales. Use provided form to document your nursing care plan. This is your work and is not a group assignment. Late papers are not accepted. The nursing care plan is worth 10 points. See syllabus for grading criteria.
Assessment
88 yo male
Social: lives alone, son lives nearby and checks on client 1X per day
Medical History: Oa X 5 yrs
Pain Scale: 6/10
Medications: Celebrex
Physical Activity: walks 2 miles X3 days per week
ADLs: Independent
Nursing
Diagnosis
Chronic Pain r/t dx of osteoarthritis aeb client report of pain in neck and right hip
Intrapersonal:
Believes pain is a normal part of aging
Dx: osteoarthritis
Pain level: 6/10
Fear of becoming addicted to pain medication
Uncomfortable rating pain on pain scale
Interpersonal
Son lives nearby and checks on him daily
Extrapersonal
Celebrex
Pain Scale
Goal
Client will function at pain level that is acceptable to him.
Outcome Criteria
Pain Control:
Client will maintain a pain diary for 1 week.
Client will function on acceptable ability level with minimal interference from pain and medication side effects within 30 days.
Client will use pain rating scale comfortably to identify current level of pain intensity, determine comfort/function goal within 1 week.
Client will demonstrate understanding or plan for pharmacological and non-pharmacological pain relief.
Nursing Intervention
Nurse will ask the client to maintain a diary of pain ratings, timing, precipitating events, medications, treatments, and steps that work best to relieve pain.
Nurse will review the client's pain diary, flow sheet, and medication records to determine the overall degree of pain relief, side effects, and analgesic requirements for 1 week.
Nurse will question the client regarding the level of pain that he believes is appropriate to achieve a state of comfort and appropriate function.
Discuss the client's fears of addiction.
Rational
Studies have shown that systematic tracking of pain was an important factor in improving pain management.
Systematic tracking of pain was found to be an important factor in improving pain management.
The pain rating that allows the client to have comfort and appropriate function should be determined: this allows a tangible way to measure outcomes of pain management.
Because of the many misconceptions regarding pain and its treatment, education about the ability to control pain effectively and corrections of myths about the use of opioids should be included as part of the treatment plan.
