Kapi’olani Community College: Associate Degree Nursing Program
Nursing Care Plan
Student Name: Karissa Higa
Date of Care:
11/8/13
Nursing Diagnosis
Acute pain
Related to:
Kidney stones
As manifested by:
Patient stating pain of 6-7 out of 10, guarding left side of body, and requesting for pain medications.
Scientific Rationale:
Date Submitted: 11/12/13
Pain is a highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors may be experienced by the sufferer. Pain may be a
symptom of injury or illness. Pain may also arise from emotional, psychological, cultural, or spiritual distress. Pain can be very difficult to explain, because it is
unique to the individual. Pain should be accepted as described by the sufferer. Pain assessment can be challenging, especially in older patients, in whom cognitive
impairment and sensory-perceptual deficits are more common.
Reference (APA format):
Gulanick, M., & Myers, J.L. (2011). Nursing care plans: Nursing diagnoses, interventions and outcomes, (7th ed.). St Louis: Mosby.
Interventions:
Rationale (w/ references):
Evaluation:
Measurable
Outcomes:
1. Assess pain
characteristics.
Short Term
2. Give analgesics as
Outcome:
ordered, evaluating
Patient’s pain reduces
effectiveness and
from a 6-7 to a 0-3 on
observing for any
a pain scale of 0-10
signs and
and uses pain
symptoms of
medications
untoward effects.
3. Evaluate the
patient's response to
pain and
medications.
4.
Respond
Long Term
immediately to
Outcome:
complaint of pain.
Patient has no pain 2- 5. Offer/encourage hot
3 days after discharge
compress
to home.
6. Instruct patient to
report pain.
7. Assess urine for
stones passed,
strain urine.
1. Assessment of the pain experience is the first step in planning pain
management strategies. The patient is the most reliable source of information
about his or her pain. Quality, severity, location, onset, duration, or relieving
factors.
2. Pain medications are absorbed and metabolized differently by patients, so the
patient must evaluate their effectiveness individually. Analgesics may cause
side effects that range from mild to life threatening.
3. It is important to help patients express as factually as possible the effect of
pain relief measures. Discrepancies between behavior or appearance and what
the patient says about pain relief may be more a reflection of other methods
that the patient is using to cope with than pain relief itself.
4. In the midst of painful experiences, a patient's perception of time may become
distorted. Anxiety and fear about delayed pain relief can exacerbate the pain
experience. Prompt responses to complaints may result in decreased anxiety
in the patient. Demonstrated concern for the patient's welfare and comfort
fosters the development of a trusting relationship.
5. Heat reduces pain through improved blood flow to the area and through
reduction of pain reflexes. Cold reduces pain, inflammation, and muscle
spasticity by decreasing the release of pain-inducing chemicals and slowing
the conduction of pain impulses.
6. Relief measures may be instituted.
7. Stones cause pain, trying to pass through ureters.
1. Pt stated she had left
flank pain 7/10, sharp,
sudden onset, and
intermittent.
2. Motrin administered.
3. Reassessed pain, pt
stated pain still 7/10, but
pt appears comfortable
in bed, watching tv, no
guarding noted, walking
around.
4. Pt stated she had pain,
administered prn motrin
5. Pt used hot compresses
for left flank pain
6. Pt understood to report
any pain, afternoon pt
reported pain to me,
6/10.
7. Two stones passed. Sent
to lab. Pt discharged to
home.