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(Planning) (3) NURSING PROCESS FORM Nursing Interventions STUDENT’S NAME: Kim
Evaluation of Goals
Rationale for Interventions * must list sources
Acute Pain related to abdominal surgical incision AEB verbal reports of pain, grimacing, moaning, and guarding of abdominal area when assessed.
Given the prescribed nursing care, the patient will have relieved/controlled pain within one hour AEB: 1. Patient verbally states relieved/decreased pain. 2. Nonverbal indicators of pain including grimacing and moaning will be absent/diminished. 3. Patient will not guard abdominal incision area during assessment.
1) Assess patient’s pain including: location, onset/duration, frequency, quality, and intensity using a pain scale of 0-10 every two hours.
1) To ensure that a patient receives effective pain relief, you must conduct a thorough and accurate pain assessment. (Lippincott, Williams & Wilkins, pg. 361) 2) Acute pain activates the sympathetic branch of the ANS causing such responses as increasing blood pressure, and rapid heart and respiratory rates. (Lippincott, Williams & Wilkins, pg. 362) 3) Behavioral and physiologic responses are indicators of pain in patients. (Searingen, pg. 40) 4) Analgesics are helpful in relieving pain and in aiding the recovery process by promoting greater ventilator excursion. (Swearingen, pg. 423) 5) Non-
Goal was met. 1. Patient verbally reported decreased pain as being “much better.” 2. Nonverbal indicators of pain were absent upon observation. 3. Patient did not guard abdominal incision area upon assessment.
2) Monitor patient’s vital signs for signs of pain including: increased heart rate, blood pressure, and respiratory rate every two hours.
3) Observe patient for nonverbal indicators of pain including: facial grimacing, moaning, guarding, and crying during assessment of pain and vital signs. 4) Administer prescribed analgesics as ordered by physician, monitor the patient’s response to pain medication 5-10 minutes after administration, and document appropriately when given. 5) Provide and teach caregivers non-pharmacologic comfort measures including repositioning and creating a low stimulus
Resources: Swearingen, Pamela. (2008). All-in-One Care Planning Resource. (2nd Edition). St. Louis, MO: Mosby, Inc. Lippincott, Williams & Wilkins. (2006). Best of Incredibly Easy! (1st Edition). Philadelphia, PA:
Wolters Kluwer. environment when patient reports pain prior to discharge. (Swearingen. pharmacologic measures support analgesia therapy in reducing pain. pg. Co. 423) REV 8/09 .