HELP!! Anxiety and Acute Pain NCP

[stressingaimee]

help!! does this sounds ok??? i have been trying desperately to get these care plans done and i always get such good info from this website but have never posted before...i have a woman who has no job, no insurance, and has been admitted d/t acute pancreatitis. i have her primary medical n dx as acute pain and her primary psychosocial as anxiety. she is super stressed about having to stay at the hospital and has no money to pay for any of this and her and her husband talked to a financial advisor who told them they could pay it over a few months but she said there is no way they could even do that. this is what i have, im not sure if it sounds good enough or anything and i guess i just want an opinion....thanks!

ndx= acute pain related to excessive alcohol intake secondary to acute pancreatitis aeb statement of pain descriptors, guarding behaviors, and changes in blood pressure and pulse.

outcome= js will rate her pain as 3 or less on a scale of 1-10 within 1 hr. of medication administration.

i know for an intervention, i should have "after administration of hydromorphone, assess for sedation and respiratory status", but at what time do i do that? this is for iv hydromorphone.

my second n dx is

ndx= anxiety (moderate) related to situational crisis aeb expressed concerns due to change in life events, restlessness, diaphoresis, increased blood pressure, uncertainty, insomnia.

outcome= js will appear relaxed and report overall decrease anxiety level by time of discharge. (does this sound right??? is it measurable enough?? this instructor is crazy tough...)

what kind of assessment data would i look for with this ndx?

do you think i have any other outcomes that are really important to these n dx's??

thank you so much!

[TessaMae]

Do you have a nursing diagnosis book? I think that would help you alot. You would not ever say acute pain related to excessive alcohol.

Heres some examples directly from the book:

Acute pain may be related to obstruction of pancreatic/biliary ducts, chemical contamination of peritoneal surfaces by pancreatic exudate/autodigestion, extension of inflammation to the retroperitoneal nerve plexus, possibly evidenced by verbal reports, guarding/distraction behaviors, self-focusing, grimacing, autonomic responses (changes in vital signs), and alteration in muscle tone.....secondary to pancreatitis.

I actually just did 2 care plans today on acute pain and anxiety but my patient had diverticulitis.

I will try to attatch some generic careplans that are from the companion website to one of my books which serve as good examples for what to include in your more specific careplans.

Hope I helped a little!

Generic_Care_Plan_for_the_Surgical_Client.pdf

Medical_Care_Plan_for_the_Hospitalized_Adult_Patient.pdf

[stressingaimee]

Thank you for your help! I have updated them...do these sound ok then??

Anxiety, moderate, related to situational crisis AEB apprehension about health status, restlessness, autonomic responses, uncertainty about payment for hospitalization costs, & insomnia.

&

Acute Pain related to pancreatic tissue damage caused by excessive alcohol intake secondary to pancreatitis AEB statement of pain descriptors, guarding behaviors, and autonomic responses.

I am still so new at these and they aren't exactly a walk in the park!

thank you so much!