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This document contains a nursing care plan for a client. The plan assesses the client's pain level, which they reported as a 6 out of 10 when moving. The objective findings were grimacing, grimacing, and shifting weight to avoid pain. The nursing diagnosis is acute pain from a surgical procedure. The short-term goal is for the client's pain to be a 4 or less by the end of the nurse's shift. The long-term goal is for pain to be managed at a level of 4 or less upon discharge. The nursing actions include assessing pain every 2 hours and teaching non-pharmacological pain management techniques. The rationale is that adjustments can be made to the pain treatment plan based on the client's
This document contains a nursing care plan for a client. The plan assesses the client's pain level, which they reported as a 6 out of 10 when moving. The objective findings were grimacing, grimacing, and shifting weight to avoid pain. The nursing diagnosis is acute pain from a surgical procedure. The short-term goal is for the client's pain to be a 4 or less by the end of the nurse's shift. The long-term goal is for pain to be managed at a level of 4 or less upon discharge. The nursing actions include assessing pain every 2 hours and teaching non-pharmacological pain management techniques. The rationale is that adjustments can be made to the pain treatment plan based on the client's
This document contains a nursing care plan for a client. The plan assesses the client's pain level, which they reported as a 6 out of 10 when moving. The objective findings were grimacing, grimacing, and shifting weight to avoid pain. The nursing diagnosis is acute pain from a surgical procedure. The short-term goal is for the client's pain to be a 4 or less by the end of the nurse's shift. The long-term goal is for pain to be managed at a level of 4 or less upon discharge. The nursing actions include assessing pain every 2 hours and teaching non-pharmacological pain management techniques. The rationale is that adjustments can be made to the pain treatment plan based on the client's
Data Base Rm 164 2 Nursing Diagnosis based on Maslows Hierar!y o" Needs# $$$$$ _________ ___ Physiological %ong&'erm (oal )!ort&'erm (oal Nursing Ations )ienti"i *ationale Evaluation )ub+etive Client complained of pain of 6 on scale of 1- 10 when moving ,b+etive Gimacing G!ading Shifting weight contin!o!sly to avoid pain "c!te pain #t s!gical poced!e "$% gimacing& g!ading& and patient stated pain level of 6 on a scale of 1 to 10 Patient will ate pain as a ' on a scale of 0 to 10 o less (y day of dischage -lient will# 1) Patient will ate pain as a * o less on a scale of 0 to 10 at the end of my shift on 10#14#14
2) Patient will demonstate how to !se non- phamacological methods to help contol pain (y the end of my shift on 10#14#14 )N will# 1) "ssess pain level evey 2 ho!s +0,'0-0-'0-11'0- 1''0) on 10#14#14 2) .each client to !se non- phamacological teatments& s!ch as deep (eathing& distaction& and theape!tic to!ch& when pain is at a (eaa(le level to them 1) can povide diection fo pain teatment plan and ad/!stments can (e made pe client0s esponse 2) distaction and othe methods sho!ld (e !sed to s!pplement pain medications Shot tem and 1ong tem goals met patient states pain is at a managea(le level of ' on a scale of 0-10 "nd has demonstated the !se of deep (eathing to manage pain