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Running head: S. STABLES, PAIN CARE PLAN Sloane Stables Integrated Care Plan: Acute Pain NURS 4560: Transition to Professional Nursing Practice Tarleton State University Diana Kunce-Collins, MS RNC-MNN October 23, 2016
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S. STABLES, PAIN CARE PLAN 2 Integrated Care Plan: Acute Pain Patient History: JD is a 30-year-old female admitted for a scheduled induction on 9/17/2016 due to poor fetal growth after 35cm. Hospital day #2. G1P0. Gestational Age 38 weeks and 4 days. Allergies to Penicillin and Amoxicillin. History of Herpes Simplex Virus; currently being treated with Acyclovir. No ETOH or tobacco use. No other significant medical history. GBS negative, Rh O-. Height 5'5". Weight 151 lbs. Medications in the hospital included Demerol, Phenergan, Ambien, Lactated Ringer’s, and Oxytocin. Cook cervical ripening balloon inserted at 0700 on 9/18/2016. Membranes intact. S: Patient states maximum acceptable pain level is 6 out of 10. Describes current pain at a level of 10 out of 10. Describes pain as sharp, cramping, and aching. States that pain is intermittent with contractions. States that she is unable to sleep d/t pain. C/o SOB during activity and when lying down. Denies abnormal bruising. Denies bleeding. O: Alert and oriented x3. Patient is calm and follows commands. Is grimacing and appears restless. Skin is cool and pink with slight pallor. Diaphoresis and alternating chills noted. BP 137/74. HR 67 bpm. Pulse Ox 99% on room air.
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  • Summer '19
  • acute pain, S. STABLES

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