Quote from lilbiskit78
Hi everyone! I am new here and in my second semester of ADN program. I am trying to write a care plan for pt. with acute pain and and having a little trouble. Is "Pt. will state pain level of 2 or less on scale of 0 to 5 during shift (0600-1300)" sound like a reasonable goal? Interventions would include administering his PRN meds round the clock (every 2 hours for morphine and every 4 for Lortab) instead of just PRN to control pain, assessing every 30 minutes, teaching nonpharmacological methods to control, ect. Any help would be greatly appreciated, teacher is VERY picky about things being individualized! Thanks!
Your care plan looks good and your goal looks good also. Here is another approach to your care plan if this will help:
Alteration in pain, related to _______________ (could be surgical procedure, or whatever reason is causing the pain), as evidenced by patient's verbalization of pain at a level 7 on scale of 10.
Patient will verbalize a pain rating of 4 or less on a scale of 10 with each assessment. (In this case, you are assessing for pain in accordance with your facility's pain management policy).
1. Pain assessment Q________ (Again, depending on your facility's pain assessment policy. Some hospitals have the nurse assess q1hour for pain above a 4 and once pain is managed at a 4 or below, assessment moves to Q4hours). Using the Visual Analog Scale (VAS).
2. Use of diversional strategies to assist with pain. (You can further individualize your plan by describing a activity that helps the patient with pain. For example, perhaps the patient likes to listen to his/her CD player. You could include this in your plan as an individualized approach).
3. Medicate in accordance with physician perscribed interventions.
4. Assist patient with positioning for comfort.
Evaluate effect of medication
Assessment of pain level
Assessment of effectiveness of diversional strategies.
Hope this helps.