Question about nursing care plan for acute pain

  1. Hello,

    I am in the "intro" semester of the ADN program and we just got our first care plan assignment based off of a case study. My patient is an 8 year old girl who presents to the emergency room with lower abdominal pain and is diagnosed with Appendicitis and is scheduled for surgery. We are to come up with 2 nursing diagnosis, one medical and one psychosocial, a short term goal and long term goal for each diagnosis and 5 interventions for each diagnosis.

    For my medical diagnosis I think I am going with Acute pain r/t diagnosis of appendicitis A.E.B. pt reports pain in lower abdomen, rebound tenderness in rt lower quadrant and elevated pulse rate.

    I was hoping to receive some feedback as to wether this is worded correctly.

    I'm also having some trouble coming up with Goals and interventions. I have a nursing care plan book, but my knowledge is so limited since this is just my intro semester that I am not sure how to individualize the interventions listed for acute pain to be appropriate for an 8 year old. This is what I have for goals and interventions. I was wondering if it was possible to get some feedback on what I have come up with so far. I've spent hours(believe it or not) working on this already and I feel like I have done it all wrong. Not sure if I'm stressing for no reason or what but it's important for me to have this done correctly. ANY help or advice/feedback would be greatly appreciated, especially advice on individualizing these interventions!

    Short term goal: Patient will verbalize pain as a 3 or less on a scale of 0-10 within 30 minutes of receiving ordered pain medication.

    Long Term goal: Patient/caregivers will describe how unrelieved pain will be managed by date of discharge.

    My interventions are
    1. Assess pain characteristics including quality, severity, location, onsent, duration and precipitating or relieving factors.
    2. Give analgesics as ordered by M.D., evaluating effectiveness and observing for any signs and symptoms of untoward effects.
    3. Assess the patients expectations for pain relief.
    4. Assess the patients willingness or ability to explore a range of techniques aimed at controlling pain.
    5. Eliminate additional stressors or sources of discomfort whenever possible.

    Thank you!!!
  2. Visit chantel2382 profile page

    About chantel2382

    Joined: Jun '13; Posts: 8; Likes: 7
    ER registrar/ Nursing student; from US


  3. by   Esme12
    This drives me plans are all about the assessment.....of the patient. I know you have to start somewhere but it is so difficult to "get the picture" from a bunch of typed words.

    Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

    So in the future.........What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...

    The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

    Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

    Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

    Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

    Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics.

    From a very wise an contributor Daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

    Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE

    1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    2. Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
    3. Planning (write measurable goals/outcomes and nursing interventions)
    4. Implementation (initiate the care plan)
    5. Evaluation (determine if goals/outcomes have been met)

    Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

    Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

    A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

    What I would suggest you do is to work the nursing process from step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at).

    The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.

    This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

    Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

    check out this thread....
    Attachment 12727Critical Thinking Flow Sheet for Nursing Students.docAttachment 12727Attachment 12727Critical Thinking Flow Sheet for Nursing Students.doc
    Last edit by Esme12 on Jul 6, '13
  4. by   Esme12
    now you think about Ericksons growth and development or what ever development resource your program uses.

    Stage Basic Conflict Important Events Outcome
    Infancy (birth to 18 months) Trust vs. Mistrust Feeding Children develop a sense of trust when caregivers provide reliabilty, care, and affection. A lack of this will lead to mistrust.
    Early Childhood (2 to 3 years) Autonomy vs. Shame and Doubt Toilet Training Children need to develop a sense of personal control over physical skills and a sense of independence. Success leads to feelings of autonomy, failure results in feelings of shame and doubt.
    Preschool (3 to 5 years) Initiative vs. Guilt Exploration Children need to begin asserting control and power over the environment. Success in this stage leads to a sense of purpose. Children who try to exert too much power experience disapproval, resulting in a sense of guilt.
    School Age (6 to 11 years) Industry vs. Inferiority School Children need to cope with new social and academic demands. Success leads to a sense of competence, while failure results in feelings of inferiority.
    Adolescence (12 to 18 years) Identity vs. Role Confusion Social Relationships Teens need to develop a sense of self and personal identity. Success leads to an ability to stay true to yourself, while failure leads to role confusion and a weak sense of self.
    Young Adulthood (19 to 40 years) Intimacy vs. Isolation Relationships Young adults need to form intimate, loving relationships with other people. Success leads to strong relationships, while failure results in loneliness and isolation.
    Middle Adulthood (40 to 65 years) Generativity vs. Stagnation Work and Parenthood Adults need to create or nurture things that will outlast them, often by having children or creating a positive change that benefits other people. Success leads to feelings of usefulness and accomplishment, while failure results in shallow involvement in the world.
    Maturity(65 to death) Ego Integrity vs. Despair Reflection on Life Older adults need to look back on life and feel a sense of fulfillment. Success at this stage leads to feelings of wisdom, while failure results in regret, bitterness, and despair.

    Eight year-olds are waking up to the wider world, and are beginning to discover more about how they fit into the bigger picture of society. If you are in charge of the care of an 8 year-old girl, it is important to recognize her growing awareness and sense of responsibility.

    Give the child a couple of chores to do. This will increase her sense of responsibility and make her feel that she is needed

    Talk about what is important to the child. Find out what interests the child has. Listen to them and take an active interest in what they say. Talk to them like they are an adult is an adult whose questions are worth listening to. After all they "aren't babies any more"

    Give the child independent play and work time.

    Build the patients confidence by helping them establish and meet goals.

  5. by   chantel2382

    Thanks for responding back to me. I thought I had considered the assessment data before I formed my nursing diagnosis and interventions. I didn't include the assessment data in my original post but I do have it.

    This is the full case study,

    KT, who is 8 years old, and her family have returned from a weekend camping trip. KT presents to the emergency room department with lower abdominal pain with nausea and vomiting. She is very tired and irritatable.

    Vital Signs: Temp=101.8

    The ER doctor ddoes a thorough history and physical examination. KT has moderate to severe tenderness in the right lower abdomen when the doctor pushes there. She has rebound tenderness. Rebound tenderness is pain that is worse when the doctor quickly releases his or her hand after gently pressing on the abdomen over the area of tenderness. An ultrasound of the abdomen is done which indicates KT has appendicitis. She is scheduled for surgery.

    All of the above is the information I used to make my nursing diagnosis. Broken down into objective and subjective data I specifically focused on the vital signs, the complaint of lower abdominal pain with nausea and vomiting, the tiredness and irritability and the findings of the doctors examination.

    All of this led me to the nursing diagnosis of Acute pain.

    I am thinking that assigning this particular 8 year old a couple of chores to do isn't really feasible in this situation considering 1. she is ill and in pain and about to have an appendectomy and 2. She's in the emergency room.

    Most of what you wrote I understand and we have covered most of that in class. I guess I was just looking for some feedback on how to effectively individualize the NANDA interventions to a child who is sick.
  6. by   chantel2382
    Thank you for your response and taking the time to write all that!! I think I forgot to mention that in the previous post!!
  7. by   Esme12
    What care plan book do you have? Over all You did OK....of course you would not assign house hold chores ...LOL...but what can you assign the child to do while hospitalized? How would you engage them in their care to feel as if they have some control? How would you prepare them for surgery? How does this affect the family dynamics?

    Other thoughts...while acute pain is important ....what would be vital to this child's recovery/survival......what could be life threatening for that would make that a priority. I ahve highlighted what caught my eye as important.
    KT, who is 8 years old, and her family have returned from a weekend camping trip. KT presents to the emergency room department with lower abdominal pain with nausea and vomiting. She is very tired and irritable.

    Vital Signs:

    The ER doctor does a thorough history and physical examination. KT has moderate to severe tenderness in the right lower abdomen when the doctor pushes there. She has rebound tenderness. Rebound tenderness is pain that is worse when the doctor quickly releases his or her hand after gently pressing on the abdomen over the area of tenderness. An ultrasound of the abdomen is done which indicates KT has appendicitis. She is scheduled for surgery.
    What does a fever mean with appendicitis?
    What is peritonitis?
    What are signs of dehydration?

    What are the normal vital signs for an 8 year old child?

    So what can hurt this child's recovery/life the most........Infection........right? fluid status.....right? You prioritize according to what will do them the most harm first...then knowing what you know about an 8 years will the impending surgery affect them and what would you do to prevent/help this?
  8. by   chantel2382
    Oh man, you know my first instinct was to choose Risk for Infection and then I questioned myself. Just shows how completely inexperienced I am at this. Thank you so much for your feedback. I think I am in for a shock next semester when I have to do multiple care plans in a week because this ONE is taking me days to complete!
  9. by   Esme12
    It gets easier and never forget....we are here! It might take me and other's that hang out here like GrnTea whop help with care plans to get back to you but we will answer.....and walk you through... OPNce you get 15 posts you can PM us as well!

  10. by   chantel2382
    Quote from Esme12
    It gets easier and never forget....we are here! It might take me and other's that hang out here like GrnTea whop help with care plans to get back to you but we will answer.....and walk you through... OPNce you get 15 posts you can PM us as well!

    Thank you!!
  11. by   chantel2382
    IN answer to your earlier question, the care plan book that I am using is Nursing Care Plans by Gulanick/Myers. This is the one the professors recommended.
  12. by   Esme12
    I have Gulanick and I also use Ackley. I like the older version of Gulanick better the one just prior but I like ackley as well the new version is awesome.
  13. by   nurseprnRN
    Sorry, I've been away. I second my friend Esme's disgust at having new nursing students being given an assignment like this, because it sets them up for the most egregious error in writing nursing plans of care there is: The idea that you write a nursing plan of care based upon a medical diagnosis. This is wrongwrongwrong and it is so unfair to make students think it is acceptable. We often want to reach right through the screen and slap those instructors silly.

    Fortunately, we can help.

    Like Esme said, they are pushing you into the classic nursing student trap of trying desperately to find a nursing diagnosis for a medical diagnosis without really looking at your assignment as a nursing assignment. You are not being asked to find an auxiliary medical diagnosis-- nursing diagnoses are not dependent on medical ones. You are not being asked to supplement the medical plan of care-- you are being asked to develop your skills to determine a nursing plan of care. This is complementary but not dependent on the medical diagnosis or plan of care.

    You are responsible for some of those components of the medical plan of care but that is not all you are responsible for. You are responsible for looking at your patient as a person who requires nursing expertise, expertise in nursing care, a wholly different scientific field with a wholly separate body of knowledge about assessment and diagnosis and treatment in it. That's where nursing assessment and subsequent diagnosis and treatment plan comes in.

    This is one of the hardest things for students to learn-- how to think like a nurse, and not like a physician appendage. Some people never do move beyond including things like "assess/monitor give meds and IVs as ordered," and they completely miss the point of nursing its own self. I know it's hard to wrap your head around when so much of what we have to know overlaps the medical diagnostic process and the medical treatment plan, and that's why nursing is so critically important to patients.

    You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.

    There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

    A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related (causative) factor(s))__."

    "Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological."

    To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic" and related factor. Defining characteristics and related factors for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). $29 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!
    If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don't care if your faculty forgot to put it on the reading list. Get it now. When you get it out of the box, first put little sticky tabs on the sections:
    1, health promotion (teaching, immunization....)
    2, nutrition (ingestion, metabolism, hydration....)
    3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)
    4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)
    5, perception and cognition (attention, orientation, cognition, communication...)
    6, self-perception (hopelessness, loneliness, self-esteem, body image...)
    7, role (family relationships, parenting, social interaction...)
    8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)
    9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)
    10, life principles (hope, spiritual, decisional conflict, nonadherence...)
    11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)
    12, comfort (physical, environmental, social...)
    13, growth and development (disproportionate, delayed...)

    Now, if you are ever again tempted (by your faculty or anything else) to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.