critique please

[catzy5]

Ok this is my first dx with goals, intervention and rationale, does it look right? am I on the right track. Please any critisism is fine I might be completely off track i am trying to do this without any back ground. So whatever info or help given is very apprectiated.

Nursing diagnosis number one .(actual) Acute pain r/t tissue trauma associated with surgery, evidenced by a patient rating of 7 on a 0-10 pain scale.

Short term goals: (1) patient will immediately at onset use pain rating scale to identify current pain intensity and determine comfort/function goal. (2) Client will report within 30 minutes that pain management regimen relieves pain to satisfactory level with acceptable and manageable side effects.

Longer term goal: (1) Client will perform activities of recovery with reported acceptable level of pain, if pain is above comfort-function goal, take immediate action that decreases pain or notify a member of health care staff.

Nursing interventions:

(1) *The nurse will determine whether the client is experiencing pain at the time of the assessment. If so, intervene at that time to provide pain relief per physician's orders.

Rationale: key to successful relief of pain is ongoing assessment (Potter & Perry, 2005, 1254/42)

(2) Have client select nonpharmacological interventions that have relieved pain in the past.

Rationale: personal control allows a client to shape immediate circumstances trhough own actions (Potter & Perry, 2005, 1249/42)

(3) Plan nursing care activities when client is comfortable based on the knowledge that oral opiod medications begin to work in approximately 1 hour and IV medications in 5-30 minutes.

Rationale: perception of pain, it is necessary to medicate before doing any activity that causes pain to decrease the perception of pain, most medications take a specific amount of time to come into effect and knowing this ahead of time the nurse can plan activities that could increase the patients pain. (Potter & Perry, 2005, 1254/42)

(4) *Nurse will call and get orders and then administer for supplemental opiod doses to keep pain rating at or below the comfort-functional goal.

Rationale: Client with chronic pain must take an analgesic regulary, even when the pain subsides, regular administration maintains therapeutic blood levels, it is sometimes necessary to use a breakthrough medication when the around the clock analgesics are not working.(Potter & Perry, 2005, 1263/42)

[richardjboro1]

They look good to me, but it helps to have the issues in the case study to see if it's appropriate. For example, pain d/t an MI would not be relieved without medical interventions, so the 2nd intervention would be incorrect. Otherwise, they all appear fine. You may expand the interventions. Depends on your program, but I try to put 7-10 interventions per diagnosis.

Richard

[catzy5]

They look good to me, but it helps to have the issues in the case study to see if it's appropriate. For example, pain d/t an MI would not be relieved without medical interventions, so the 2nd intervention would be incorrect. Otherwise, they all appear fine. You may expand the interventions. Depends on your program, but I try to put 7-10 interventions per diagnosis.

Richard

oh good grief 10 lol I am barely making the 3 atleast for this round and my lack of experience.

I wish I had a case study to go on, unfortunately just what I wrote down in my notes from the chart is all I am going on.

[richardjboro1]

Do you have the chief complaint and diagnoses then? That would help those perusing your post to advise on the interventions and appropriate nsg diagnoses.

R

[catzy5]

Do you have the chief complaint and diagnoses then? That would help those perusing your post to advise on the interventions and appropriate nsg diagnoses.

R

I am not even sure I know what that means.

She is in day one post op for hip replacement, the only complaint I could come up with was pain, her recovery was going very well, she was quite anxious about doing PT and having to move, other then that her drain looked good, vitals were all good.

[richardjboro1]

chief complaint is why she's in the hospital in the first place. So, in this case it sounds like some kind of surgery. So you would write the chief complaint as: Pt in for removal of.......whatever it was and is one day post-op. Other diagnoses may be CHF, a fib, COPD, emphysema, etc etc etc.....Hope that helps.

R