NURSING CARE PLAN
SCENARIO: Pt presents or ER with complaints of left sided abdominal pain
PATHOPHYSIOLOGY: Unknown
ASSESSMENT
DIAGNOSIS
SUBJECTIVE: Pt
states he has
pain on the left
side, feels cold.
Pain of 10 out of
10.
OBJECTIVE:
Guarding,
grimacing, tense
muscles, sudden
change increase
in pain, moaning,
crying
Objective Data:
Age: 24
HT: 58
WT: 175
Allergies:
NKDA (No Known
Drug Allergies)
Acute Pain r/t
injury,
pathological
process
(Ladwig, 2022)
page 114.
PLANNING/OUTCOMES
(Short Term Goal)
Patient will experience a
decrease in pain from 10
to less than 4.
INTERVENTIONS
A. Assess
1. Assess the pain
using 1-10 scale.
RATIONALE FOR
INTERVENTIONS
1. To establish a
baseline pain level
and understand
patients tolerance.
Initial assessment and
interview, if the client is
experiencing pain,
conduct and
document a
comprehensive pain
assessment, using
appropriate pain
assessment tools.
(Ladwig, 2022) page
1108.
A pain assessment
tool consists of
obtaining all the
information that a
client can
provide to help
individualize a pain
management plan of
care. (Ladwig,
2022) page 1108.
C: Collaborate
2.Administer pain
medication as ordered
by Dr.
2. To minimize the
pain and see how it
affects the pain
EVALUATION
1. Pain is a
10/10 (Met)
2. 1400:
Morphine 10
mg given IV
Ackley, B. J., Ladwig, G. B., Flynn, M. M. B., Martinez-Kratz, M. R., & Zanotti, M. (2022). Nursing diagnosis handbook: An
evidence-based guide to planning care. Elsevier.
ND: Section II
pages 109-347
Note pg 112 for
easy access to
diagnosis
ND INDEX: page
1501
Advocate for and
manage acute pain
using a multimodal,
opioid-sparing
approach. (Ladwig,
2022) page 1189
A multimodal
approach
(combining two or
more drugs that act
by different
mechanisms
for providing
analgesia) enhances
pain relief and
allows the lowest
effective dose of
each drug
to be administered,
resulting in fewer or
less severe side
effects, such as
nausea, sedation,
and
respiratory
depression .
(Ladwig, 2022)
page 1189
T: Teach
3. Teach the client
about pain and
pharmacological and
nonpharmacological
3. No Rational
Interventions:
Section III
Pages 348-1499
Alphabetized
Interventions
INDEX: page 346347
(intravenously)
(Met)
3. Unable to do
effective
teaching due to
Ackley, B. J., Ladwig, G. B., Flynn, M. M. B., Martinez-Kratz, M. R., & Zanotti, M. (2022). Nursing diagnosis handbook: An
evidence-based guide to planning care. Elsevier.
interventions when
pain is relatively well
controlled. (Ladwig,
2022) page 1189 No
rational
Explain to the client the
pain management
approach, including
pharmacological
and
nonpharmacological
interventions, the
assessment and
reassessment process,
potential side effects,
and the importance of
prompt reporting of
unrelieved pain. .
(Ladwig, 2022) page
1189
patient being
prepped for
surgery due to
pain. (Not Met)
One of the most
important steps
toward improved
control of pain is a
better client
understanding of the
nature of pain, its
treatment, and the
role the client needs
to play in pain.
(Ladwig, 2022)
page 1189
Post Surgery
Acute Pain r/t
surgical
procedure
(Ladwig, 2022)
page 114.
Ackley, B. J., Ladwig, G. B., Flynn, M. M. B., Martinez-Kratz, M. R., & Zanotti, M. (2022). Nursing diagnosis handbook: An
evidence-based guide to planning care. Elsevier.
Ackley, B. J., Ladwig, G. B., Flynn, M. M. B., Martinez-Kratz, M. R., & Zanotti, M. (2022). Nursing diagnosis handbook: An
evidence-based guide to planning care. Elsevier.