Stacie Smith

Assess/Analyze Plan Implement Evaluate

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