Assessment

  1. Patient’s complaint of acute pain (location, intensity, and characteristics).
  2. Vital signs: note any elevated blood pressure, heart rate, or respiratory rate.
  3. Patient’s verbalization of discomfort and distress.
  4. Physical assessment findings related to pain (e.g., guarding, facial expressions).
  5. Patient’s self-report of pain level on a scale of 0-10.

Nursing Diagnosis

  • Acute pain related to [cause of pain] as evidenced by verbal reports of pain, elevated vital signs, and physical assessment findings.

Planning

  1. The patient will report a pain level of 4 or lower on a scale of 0-10 within [timeframe].
  2. The patient will demonstrate improved coping mechanisms and reduced anxiety related to pain.
  3. The patient will adhere to the prescribed pain management plan.

Implementation

  1. Regularly assess the patient’s pain using a validated pain scale (e.g., Numeric Rating Scale or Wong-Baker FACES scale).
  2. Evaluate pain characteristics, location, and factors that aggravate or alleviate the pain.
  3. Pain Medication Administration:
  4. Administer pain medications as prescribed by the physician and document the effectiveness of each medication.
  5. Monitor the patient’s response to pain medications, including any side effects or adverse reactions.
  6. Educate the patient about the importance of taking medications on time and avoiding self-medication.
  7. Offer non-pharmacological pain relief methods such as relaxation techniques, guided imagery, deep breathing exercises, or distraction techniques.
  8. Provide a calm and supportive environment to reduce anxiety and stress, which may exacerbate pain.
  9. Help the patient find comfortable positions that alleviate pain and minimize pressure on affected areas.
  10. Provide supportive pillows or cushions to enhance comfort.
  11. Apply ice packs or warm compresses, as appropriate, to the affected area for pain relief.
  12. Collaboration with the Interdisciplinary Team:
  13. Collaborate with the physician, physical therapist, and other healthcare professionals to develop an effective pain management plan.
  14. Implement prescribed treatments and therapies as indicated.
  15. Educate the patient and their family about the nature of acute pain, the expected course of recovery, and the importance of adhering to the pain management plan.
  16. Provide information about potential side effects of medications and measures to address them.
  17. Encourage open communication with the patient to address any concerns or questions they may have about pain management.

Evaluation

  1. Regularly reassess the patient’s pain level and response to interventions.
  2. Evaluate the patient’s progress toward achieving the stated goals.
  3. Modify the care plan as needed based on the patient’s response to treatment.

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