2. Encourage client to express any questions or concerns she may have regarding pain management methods to alleviate anxiety and fears. 3. Educate the client on her responsibility to honestly report pain when it occurs as well as reporting if the current pain management is effective or ineffective for providing her pain relief 1. “There are many ways to manage pain. In addition to pharmacologic and non- pharmacologic measures, simple nursing interventions can alter patients’ pain experience and speed their recovery.” Taylor, Lillis & White, 2007, pg. 1168. 2. “Common fears include a loss of control and embarrassment by being unable to deal with pain maturely… The patient may view the need of for medication as a sign of weakness or may fear addiction or loss of effectiveness at a later date.” Taylor, Lillis & White, 2007, pg. 1169. 3. “As a patient advocate, ensure that a strong emphasis on the need for aggressive, individualized strategies that can minimize or eliminate acute pain and improve patient outcomes. Preventing pain is easier then treating it once after it occurs.” Taylor, Lillis & White, 2007, pg. 1178. Short Term Goal: Met; pain was rated at a 2 on a scale of 0 to 10 after administration of Vicodin. Long Term Goal. In progress OBJECTIVE DATA: Alert and oriented 70 year old widowed female. Lives in an apartment independently. 2 daughter live nearby and visit often. History of a fall while out shopping 1 ½ weeks ago. Right hip surgically repaired 7 days ago. Surgical dressing to right hip is clean, dry and intact. Circulation, motion and sensation intact to right lower extremity. Afebrile; BP 124/80; R-18 AP 84 and regular. 5 foot 7 inches weighs 142 pounds. No hearing deficits; wears eye glasses Medical history positive for osteoarthritis and osteoporosis Non weight bearing to right leg and to use a walker for ambulation To start physical therapy for gait and strength training BID times 7 days and occupational therapy to develop upper body strength once daily times 7 days Reports pain level is at 8 on a scale of 0 to 10. LONG TERM: Client will report pain level of 2 or less using ibuprofen with alternative pain control methods by discharge. 11
Has Vicodin 5mg/325 mg po 2 tabs every 4 hours prn for severe pain Ibuprofen 400 mg every 6 hours prn for moderate pain. Short term outcome : An outcome that can be accomplished by the end of the student clinical day. Long term outcome : An outcome that can be accomplished by a week, a month or by discharge. Interventions: Each nursing intervention must come from a reliable nursing reference or source. Please note: do not use nursing care planning book exclusively. Not more than one intervention can come from a source outside your textbooks. Scientific Rationales: Give enough of the text to validate your intervention. Cite a reliable source for each intervention (name of text, author, page number, internet site and date retrieved (reliable sites: .gov or .edu. or .org) NANDA DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED BY STATEMENT: ASSESSMENT (Data that directly pertains to
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- Fall '18
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- The Bible