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 progressOBJECTIVE DATA:Alert and oriented 70 year old widowed female. Lives in an apartment independently. 2 daughter live nearbyand 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 osteoporosisNon weight bearing to right leg and to use a walker forambulationTo start physical therapy for gait and strength training BID times 7 days and occupational therapy to develop upper body strength once daily times 7 daysReports pain level is at 8 on a scale of 0 to 10.Has Vicodin 5mg/325 mg po 2 tabs every 4 hours prn for severe painIbuprofen 400 mg every 6 hours prn for moderate pain.LONG TERM: Client will report pain level of 2 or less using ibuprofen with alternative pain control methods by discharge.Short term outcome: An outcome that can be accomplished by the end of the student clinical day. Longterm 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 interventioncan 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:10
ASSESSMENT (Data that directly pertains tothe above nursing diagnosis)OUTCOME STATEMENT(Patient centered, realistic,specific, measurable, targettime)INTERVENTIONS(Individualized, specific,frequency)SCIENTIFIC RATIONALE(Supporting statement fromtext or other source, citesource using in-text citation)EVALUATION OF OUTCOME(Met, partially met, unmet,unknown by target time)SUBJECTIVE DATA: SHORT TERM:126.96.36.199.2.3.SHORT TERM:LONG TERM:OBJECTIVE DATA:LONG TERM: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 and be individualized to the client.
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- Fall '18
- Allie Kotzian
- Generic Name