Nursing Care Plan

Foundations of Nursing I 8200:211

Nursing Diagnosis Goal/Outcomes (3) Nursing Interventions Scientific Rationale Evaluation and Modification
Diagnostic affected describe and provide guided imagery has joint replacements.”
nonpharmacological education regarding shown a reduction in
Statement: 1a. 1a.
Acute pain related to 1.
methods that can be The nurse will the use of “The use of pain and anxiety 1.
The client will used to to help identify, implement, non-pharmacological structured touch and among adults who
inflammation in
interventions underwent elective
achieve comfort-function goal by The nurse will assist client to self control personal efficacy
identify resources for coping
Ref: and active participation in his or
the end of the shift.
extremity and osteomyelitis with psychological impact of 1b. her own care.”
AEB positioning to ease pain “Cognitive behavioral strategies
pain.
intensity 1b. can restore the clients sense of Ref:
rest and sleep within 48 administer analgesics or breakthrough pain. PRN medications alone periods of excessive
2.
N/A hours. around the clock for will lead to periods of medication and adverse
Subjective 2a.
The client will state continuous pain and as “If pain is present most under medication and effects.”
Data: 2a.
ability to obtain needed for intermittent of the day, the use of poor pain control and
The nurse will 2.
sufficient amounts of
whenever possible. in chest tube removal,
wound drain removal, and
2b. 3a. Ref: 2b. arterial line insertion are
identified as the most painful
procedures. The use of
topical lidocaine 1% before
Ref: 3a. removal of extremity
The nurse will prevent
“Adult clients in the
vacuum-assisted closure 3.
pain by administering wound dressings results in
intensive care setting
analgesia before reduced pain and opioid
experience numerous
painful procedures use.”
sources of procedural pain
3.
of the calcaneus with The nurse will conduct a identify a goal that will allow the
Objective Data:
surrounding edema focused assessment on the client to perform necessary or
Stage two pressure wounds to
Repositioning every two hours client’s pain. desired activities easily.
coccyx The client will use a self-report
Unstageable pressure wound to pain tool to identify current pain Ref:
left heel “Determining location, temporal aspects,
intensity level and establish a
Generalized edema comfort-function goal within 24 3b. pain intensity, characteristics, and the

MRI indication of osteomyelitis The nurse will ask the client to Ref: 3b. effective pain and function and
hours. quality-of-life are critical to determine
underlying cause of pain and
effectiveness of treatment.”

“The comfort-function goal

provides the basis for
individualized pain
management plans and assist in
determining effectiveness of pain
management interventions.”