Broward Community College Department of Nursing Technology

PATIENT CARE PLAN

STUDENT Gregory Gunter PATIENT'S INITIALS E.C. AGE ADMITTING DIAGNOSIS/DATE CHF SURGICAL PROCEDURE/DATE N/A 92 SEX Female DATE 1/18/2011 OTHER MEDICAL DIAGNOSIS Diabetes

NURSING DIAGNOSIS (in priority order)

PATIENT-CENTERED GOALS

NURSING INTERVENTION

RATIONALE 1. It is subjective in nature, and only the patient can fully describe it. (Coxs pg. 487) Pain is more readily controlled when it is treated early. (Coxs pg. 487) Response to pain and pain medication is unique to each patient. (Coxs pg. 488) Promotes action and effect of medication by providing decreased stimuli. (Coxs pg. 488) Detects early changes that might indicate pain. (Coxs pg. 488)

EVALUATION

Pain, acute; Related to: Swollen right leg. As evidenced by: Subjective statement: Patient stated, I feel pain in my right leg. So please be careful how you move it. Objective data: Facial grimace observed upon slight movement of patients right leg. Patient pulls right leg away when you attempt to touch it.

Short term goal: Patient will verbalize relief of pain one hour after medicating each shift. Long term goal: Patient will verbalize pain is under control or rid of prior to discharge.

1. Monitor for pain at least every 2 hours. 2. Teach patient to report pain as soon as it starts. 3. Administer pain medication as prescribed. Reassess and document amount of pain relief within 30 minutes after administration. 4. Provide calm quite environment. 5. Monitor vital signs at least every 4 hours while awake at times.

2. 3.

Short term goal met: During hourly rounds patient states a relief of pain following pain medication administration. Long term goal pending: Still verifying underlining cause of patients pain.

4.

5.