NUR 590 Evidence Based Project Proposal Evaluation Plan

Nursing Care Plan and Diagnosis for Chronic Pain

Nursing Care Plan and Diagnosis for Chronic Pain

This nursing care plan is designed for patients with chronic discomfort. According to Nanda,

chronic pain is the condition in which an individual experiences persistent or intermittent pain

that lasts for more than six months. This definition differs from that of acute pain, in which a

person experiences agony from one second to six months.

The patient may report typical symptoms of distress, but they have persisted for at least six

months. Due to the patient experiencing these symptoms for more than six months, the nurse

may observe social and familial relationship disruption, irritability, depression, a "beaten"

appearance, exhaustion, or somatic preoccupation.

There are numerous causes of chronic pain, including musculoskeletal disorders such as back

pain, treatment-related therapies such as chemotherapy, and pregnancy.

This nursing care plan for chronic back pain includes a nursing diagnosis, nursing interventions,

and nursing objectives.

What are intentions for geriatric care? How is a nursing care plan developed? Which nursing

care plan literature would you recommend to assist in the creation of a nursing care plan?

Care Plans are frequently developed in various formats. The format is not always crucial, and the

format of care plans may vary between nursing institutions and medical employment. Some

hospitals may display the information digitally or utilize pre-made templates. The most essential

aspect of the care plan is its content, as it will serve as the basis for your care.

Nursing Care Plan for Chronic Pain

Please observe the video below for a tutorial on how to construct a care plan in nursing school.

Otherwise, please continue down to view the finished care plan.

Scenario

A 56-year-old male presents with complaints of back discomfort. He states that he has

experienced consistent lower back pain for the past year. He explains that he decided to come in

to have it "checked out" because it is "taking a toll" on his ability to function. He reports that the

back pain has left him despondent and exhausted because he cannot perform the same tasks he

did a year ago. He also reports that his relationship with his wife and children has been affected.

You observe that the patient appears fatigued with dark circles under his eyes and is frequently

rubbing his back.

Nursing Diagnosis

Inflammation of the lumbar spine is the cause of the patient's one-year history of consistent

lower back pain, disruption of social and familial relationships, depression, fatigue, a "beaten

look," and rubbing of the painful area.

Subjective Data

He states that he has experienced consistent lower back pain for the past year. He explains that

he decided to come in to have it "checked out" because it is "taking a toll" on his ability to

function. He reports that the back pain has left him despondent and exhausted because he cannot

perform the same tasks he did a year ago. He also reports that his relationship with his wife and

children has been affected.

Objective Data

A 56-year-old male presents with complaints of back discomfort. You observe that the patient

appears fatigued with dark circles under his eyes and is frequently rubbing his back.

Nursing Outcomes

-At the next follow-up appointment, the patient will report an improvement in back pain and an

increase in daily activities.

-The patient will verbalize his expectations regarding the course of pain treatment and his

intended treatment outcomes and objectives.

-The patient will identify five noninvasive pain relief methods to aid in pain management.

-The patient will be instructed verbally on how to take the back pain medication prescribed for

him as needed.

Nursing Interventions

At the next follow-up appointment, the nurse will evaluate the patient's report of reduced back

pain and an increase in daily activities.

-The nurse will evaluate the patient's expectations regarding the duration of pain treatment and

his desired treatment outcomes.

-The nurse will educate the patient on five noninvasive pain relief techniques to aid in pain

management.

-The nurse will instruct the patient on how to take the back pain medication prescribed for him as

needed.

SAMPLE Block format Soap Note

PATIENT INFORMATION

Name: Mr. W.S.

Age: 65-year-old

Sex: Male

Source: Patient

Allergies: None

Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime

PMH: Hypercholesterolemia

Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.

Surgical History: Appendectomy 47 years ago.

Family History: Father- died 81 does not report information

Mother-alive, 88 years old, Diabetes Mellitus, HTN

Daughter-alive, 34 years old, healthy

Social Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on

social celebrations. Retired, widow, he lives alone.

SUBJECTIVE:

Chief complain: “headaches” that started two weeks ago

Symptom analysis/HPI:

The patient is 65 years old male who complaining of episodes of headaches and on 3 different

occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100

respectively). Patient noticed the problem started two weeks ago and sometimes it is

accompanied by dizziness. He states that he has been under stress in his workplace for the last

month.

Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.

ROS:

CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss.

NEUROLOGIC: Headache and dizzeness as describe above. Denies changes in LOC. Denies

history of tremors or seizures.

HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in

vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or

drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain,

hoarseness, difficulty swallowing.

Respiratory: Patient denies shortness of breath, cough or hemoptysis.

Cardiovascular: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal

dyspnea.

Gastrointestinal: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or

diarrhea.

Genitourinary: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty

starting/stopping stream of urine or incontinence.

MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.

Skin: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.

Objective Data

CONSTITUTIONAL: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20,

PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 0/10.

General appearance: The patient is alert and oriented x 3. No acute distress noted.

NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation

intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.

HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no

tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye

movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema,

or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary

sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without

lesions,.Lids non-remarkable and appropriate for race.

Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling

or masses.

Cardiovascular: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2

sec.

Respiratory: No dyspnea or use of accessory muscles observed. No egophony, whispered

pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on

auscultation.

Gastrointestinal: No mass or hernia observed. Upon auscultation, bowel sounds present in all

four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no

rebound no distention or organomegaly noted on palpation

Musculoskeletal: No pain to palpation. Active and passive ROM within normal limits, no

stiffness.

Integumentary: intact, no lesions or rashes, no cyanosis or jaundice.

Assessment

Essential (Primary) Hypertension (ICD10 I10): Given the symptoms and high blood pressure

(156/92 mmhg), classified as stage 2. Once the organic cause of hypertension has been ruled out,

such as renal, adrenal or thyroid, this diagnosis is confirmed.

Differential diagnosis:

Ø Renal artery stenosis (ICD10 I70.1)

Ø Chronic kidney disease (ICD10 I12.9)

Ø Hyperthyroidism (ICD10 E05.90)

Plan

Diagnosis is based on the clinical evaluation through history, physical examination, and routine

laboratory tests to assess risk factors, reveal identifiable causes and detect target-organ damage,

including evidence of cardiovascular disease.

These basic laboratory tests are:

· CMP

· Complete blood count

· Lipid profile

· Thyroid-stimulating hormone

· Urinalysis

· Electrocardiogram

Ø Pharmacological treatment:

The treatment of choice in this case would be:

Thiazide-like diuretic and/or a CCB

· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily.

Ø Non-Pharmacologic treatment:

· Weight loss

· Healthy diet (DASH dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat

dairy products with reduced content of saturated and trans l fat

· Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but at least 1,000 mg/d

reduction in most adults

· Enhanced intake of dietary potassium

· Regular physical activity (Aerobic): 90–150 min/wk

· Tobacco cessation

· Measures to release stress and effective coping mechanisms.

Education

· Provide with nutrition/dietary information.

· Daily blood pressure monitoring at home twice a day for 7 days, keep a record, bring the record

on the next visit with her PCP

· Instruction about medication intake compliance.

· Education of possible complications such as stroke, heart attack, and other problems.

· Patient was educated on course of hypertension, as well as warning signs and symptoms, which

could indicate the need to attend the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes

understanding to all

Follow-ups/Referrals

· Evaluation with PCP in 1 weeks for managing blood pressure and to evaluate current

hypotensive therapy. Urgent Care visit prn.

· No referrals needed at this time.

References

Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017

(25th ed.). Print (The 5-Minute Consult Series).

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).

ISBN 978-0-8261-3424-0

Patient Assessment and Care Plan

Instructions to student:

1) Bring one copy of this packet with you to clinical each week.

2) Your instructor will inform you of the number of packets and the dates each packet is due.

They may have you complete only portions of or all of the packet.

3) Read the rubric! Each packet is Pass/Fail. You must meet the requirements listed to receive a

Pass. Your instructor may ask you to resubmit packets that are incomplete or incorrect.

4) If your instructor asks you to submit the packet electronically, then please record your answers

in bold or in a colored or lower case font. This helps us identify your answers more quickly.

PATIENT ASSESSMENT FORM

STUDENT NAME: DATE:

CLIENT INITIALS: ROOM # DOB: AGE GENDE

R:

ADMISSIO

N DATE:

CODE STATUS: ALLERGIES: MARITAL

STATUS:

OCCUPATIO

N

(FORMER):

MEDICAL DX:

CHIEF

COMPLAINT

:

PAST HISTORY

(SURGERY/PROCEDUR

ES) WITH DATES

ORDERS

RATIONAL

E (Why is

this ordered

for this

client???)

EXAMPLE: DIET

2 g Sodium

diet with

nectar thick

liquids only

Sodium is

restricted due

to edema in

the bilateral

lower

extremities

and nectar

thick liquids

due to

dysphagia

from a past

stroke.

DIET

ACTIVITY

I/O

VS

BGM

FOLEY

NG

PEG/PEJ TUBE

WOUND CARE

RESPIRATORY

TREATMENT

TRACHEOSTOMY

SUCTIONING

CHEST TUBE

SPECIAL EQUIPMENT

LAB ORDERS

OTHER

REHAB SERVICES ACTIVITY

OR

RATIONAL

E

TREATMEN

T PLAN &

SCHEDULE

PHYSICAL THERAPY

SPEECH THERAPY

OCCUPATIONAL

THERAPY

....../ 5 pts

IVs

IV FLUID AND RATE: SITE LOCATION AND CONDITION:

LAST DRESSING CHANGE: LAST TUBING CHANGE:

GAUGE: REASON FOR IV ACCESS:

DIAGNOSTIC

TESTS: DATE RESULTS

REASON FOR TESTING AND

IMPLICATIONS FOR NURSING CARE

LAB

TEST DATE RESULTS

NORMS

REFERENCE

RANGES

IMPLICATIONS FOR NURSING CARE

(WHAT S&S I SHOULD BE AWARE OF

AND WHAT YOU CAN DO TO HELP

IMPROVE AN ABNORMAL RESULT?)

GROWTH and DEVELOPMENT: (see pages 378-379 Taylor, Lillis and White) or (Erikson’s

Stages of Development)

CLIENT’S DEVELOPMENTAL STAGE ACCORDING TO

HAVIGHUSRT

TASKS OF THIS

STAGE:

ASSESSMENT OF CLIENT’S SUCESSFUL ACHIEVEMENT OF

TASKS

...../ 5 pts

MEDICATIONS

If your client has more than 12 medications, select the 12 medications that are most important,

most frequently given or those that pertain to the client’s most significant medical problems. See

the example below.

Brand Name and Generic Name Normal Dosage Ranges Contraindications

Coreg (carvedilol)

3.125 mg – 50 mg BID Asthma, heart block

Pharmacotherapeutic Class Dosage, Route & Frequency Adverse Reactions

β-adrenergic blocker

6.25 mg p.o. BID

Bradycardia, CHF,

thrombocytopenia,

hyperglycemia, bronchospasm

Why this Patient Receives this

Med

Effects of the Med on the

Client

Nursing Considerations and

Teaching

He has a history of hypertension

but has been taking Coreg for 2

years to control his hypertension

BP’s for past 3 days have

been 128/78, 132/72, 138/80

How is this medication

impacting your client??B/P

readings, lab results, pain

management, etc……..

Do not discontinue abruptly or

before surgery

Caution with Upper airway

dysfunction

Rise slowly to minimize

orthostatic hypotension, check

B/P and heart rate prior to

administration

Take before meals

#1 Brand Name and Generic

Name Normal Dosage Ranges Contraindications

Pharmacotherapeutic Class Dosage, Route &

Frequency Adverse Reactions

Why this Patient Receives this

Med

Effects of the Med on the

Client

Nursing Considerations and

Teaching

#2 Brand Name and Generic

Name Normal Dosage Ranges Contraindications

#3 Pharmacotherapeutic Class Dosage, Route and

Frequency Adverse Reactions

Why this Patient Receives this

Med

Effects of the Med on the

Client

Nursing Considerations and

Teaching

#4 Brand Name and Generic

Name Normal Dosage Ranges Contraindications

Pharmacotherapeutic Class Dosage, Route and

Frequency Adverse Reactions

Why this Patient Receives this

Med

Effects of the Med on the

Client

Nursing Considerations and

Teaching

#5 Brand Name and Generic

Name Normal Dosage Ranges Contraindications

Pharmacotherapeutic Class Dosage, Route and

Frequency Adverse Reactions

Why this Patient Receives this

Med

Effects of the Med on the

Client

Nursing Considerations and

Teaching

# 6 Brand Name and Generic

Name Normal Dosage Ranges Contraindications

Pharmacotherapeutic Class Dosage, Route and

Frequency Adverse Reactions

Why this Patient Receives this

Med

Effects of the Med on the

Client

Nursing Considerations and

Teaching

#7 Brand Name and Generic

Name Normal Dosage Ranges Contraindications

Pharmacotherapeutic Class Dosage, Route and

Frequency Adverse Reactions

Why this Patient Receives this

Med

Effects of the Med on the

Client

Nursing Considerations and

Teaching

#8 Brand Name and Generic

Name Normal Dosage Ranges Contraindications

Pharmacotherapeutic Class Dosage, Route and

Frequency Adverse Reactions

Why this Patient Receives this

Med

Effects of the Med on the

Client

Nursing Considerations and

Teaching

#9 Brand Name and Generic

Name Normal Dosage Ranges Contraindications

Pharmacotherapeutic Class Dosage, Route and

Frequency Adverse Reactions

Why this Patient Receives this

Med

Effects of the Med on the

Client

Nursing Considerations and

Teaching

#10 Brand Name and Generic

Name Normal Dosage Ranges Contraindications

Pharmacotherapeutic Class Dosage, Route and

Frequency Adverse Reactions

Why this Patient Receives this

Med

Effects of the Med on the

Client

Nursing Considerations and

Teaching

#11 Brand Name and Generic

Name Normal Dosage Ranges Contraindications

Pharmacotherapeutic Class Dosage, Route and

Frequency Adverse Reactions

Why this Patient Receives this

Med

Effects of the Med on the

Client

Nursing Considerations and

Teaching

#12 Brand Name and Generic

Name Normal Dosage Ranges Contraindications

Pharmacotherapeutic Class Dosage, Route and

Frequency Adverse Reactions

Why this Patient Receives this

Med

Effects of the Med on the

Client

Nursing Considerations and

Teaching

...../ 20 pts

NURSES NOTES FOR CLINICAL

For this clinical, we are having you write out your assessment findings in the form of a narrative

nurse’s note. We have provided some samples of assessments. We have also provided a

worksheet that you may use to take into a patient’s room to take notes during your assessment.

Record your vital signs and type your physical assessment findings. This form will expand to fit

your typing. A sample of charting for a long

resident follows below.

TEMP: APICAL HR: RESP: BP: HT: WT:

DATE / TIME

(TYPE HERE)

Sample Narrative Note --- Head to Toe format

Temp: 98.6 Apical HR: 72 Resp: 16 BP 128/62 Ht: 5’10” Wt: 145

12/22/2010

1400

Resident in semi-fowlers position in bed. Pressure reduction mattress in place.

Alert and oriented x 3. Appropriate mood and affect. Well groomed. Recent and

remote memory intact. Facial symmetry noted. Pupils are equal, reactive to light

and accommodation. Oral mucosa moist, pink. Frequent oral care rendered with

sponge toothette and toothbrush. Dentition intact. Hearing intact. Oropharynx clear

without erythema or exudate. No chewing or swallowing difficulties. 75% of

general diet taken at breakfast. Skin pink, warm, dry, free of lesions with elastic

turgor. Hair and nails unremarkable. Carotid and radial pulses present and equal.

Motor and sensory functions grossly intact. No weakness or paralysis. Upper

extremities equal strength bilaterally, full ROM w/ capillary refill < 3 sec. Fine

resting tremor in the left hand” No involuntary movement or abnormal posture.

Lungs clear bilaterally to auscultation. Tracheostomy dressing clean, dry, and

intact. Connected to ventilator with settings: TV-550, Fio2-40%, Rate 10, and

PEEP-5cm. Sao2-92%. Suctioned for moderate amount of white, thin secretion.

Apical pulse regular (rate) and rhythm. Double lumen picc line note to left

antecubital space. Tegaderm dressing is clean, dry, and intact. Last dressing

change on 11/28/16. Chlorhexadine caps intact to all lumens. Bowel sounds active

x 4. Abdomen soft, non-distended, non-tender. Last bowel movement this

morning, passed a large, soft- formed brown stool and a moderate amount of clear

yellow urine. Bilateral lower extremities, no tenderness, swelling or joint

deformities noted. Denies numbness or tingling to extremities. Toe nails thick and

yellowed w/ capillary refill < 3 sec. No peripheral edema noted, pedal pulses

palpable and equal bilaterally.

PHYSICAL ASSESSMENT WORKSHEET (Use this sheet for jotting down

your assessment findings.)

ROUTINE FINDINGS PATIENT VARIATIONS/ABNORMALS

COGNITION/NEUROLOGICAL (SAMPLE)

Alert and oriented x3, recent and remote

memory intact. Denies any numbness or

tingling to extremities”

(SAMPLE) “Fine resting tremor of left hand

SKIN

SENSORY

Wound measurements and complete

description if available at the very least

Document dressing including the type of

dressing and description of condition!

BREASTS - DEFERRED.

RESPIRATORY –

(Include ventilator settings as indicated in

narrative note)

CARDIOVASCULAR

Include any vascular access device, IV lines,

AV fistulas, perma -cath lines, etc.

ABDOMEN –

.

Include any enteral feedings here and route

BOWEL CONTINENCE? LAST BM?

BOWEL PLAN?

MUSCULOSKELETAL -

GENITOURINARY -

URINARY CONTINENCE? TOILETING

PLAN?

PELVIC -

DEFERRED.

RECTAL - DEFERRED.

....../ 10 pts

NURSING CARE PLAN Begin your NCP by listing ALL your clients individual problems (at

least 10) and then identify an appropriate nursing diagnosis that you can think of that would

apply to your client. Determine which 3 problems/nursing diagnoses are of greatest priority and

then add a #1, #2, and #3 to indicate which of the two have highest priority. Risks would not be

priority 1, 2, or 3!!!!!

Expectation is to have at least 10 nursing diagnosis listed!

# List the Client

problem

An appropriate

Nursing Diagnosis

stem

(REFER TO YOUR

NURSING

DIAGNOSIS LIST)

Related to part of the

statement (This is

individual to your

client)

As evidenced by part of the

statement (This is

individual to your client)

REMEMEBR THIS IS

NOT USED IN A “Risk

For” diagnosis

1

SAMPLE:

Reports severe

pain in the right

hip.

“Acute Pain” “related to” fractured

right hip

“as evidenced by” verbal

report of pain rated at an 8

on a scale of 0 –to 10.

2 SAMPLE:

Complete bed rest

“Risk for Impaired

skin integrity”

“related to “

immobility

NONE it is a “Risk for”

diagnosis so there is no

evidence statement

From the list above your faculty member will give you direction regarding how many and which

diagnoses they want you to develop for either a Nursing Care Plan and/or a Concept Map.

SAMPLE NCP

NANDA DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED

BY STATEMENT: Acute Pain related to right hip fracture as evidenced by a verbal

report of pain rated 8 on a scale of 0 -10.

ASSESSMEN

T

(Data that

directly

pertains to the

above nursing

diagnosis)

OUTCOME

STATEMEN

T

(Patient

centered,

realistic,

specific,

measurable,

target time)

INTERVENTIONS

(Individualized,

specific, frequency)

Minimum of 4-5

interventions per plan

SCIENTIFIC

RATIONALE

(Supporting statement

from text or other

source, cite source)

EVALUATIO

N OF

OUTCOME

(Met, partially

met, unmet,

unknown by

target time)

SUBJECTIVE

DATA: “My

right hip hurts

me so much

every time I

move. I am so

afraid to start

physical

therapy”

SHORT

TERM:

Client will

report pain

level rated at

a 3 or lower

30 minutes

after pain

medication

taken

1. Educate the client on

the importance of pain

relief to enhance her

rehabilitation efforts

and include education

on various types of

methods to relieve pain.

2. Encourage client to

express any questions

or concerns she may

have regarding pain

management methods

1. “There are many

ways to manage pain. In

addition to

pharmacologic and non-

pharmacologic

measures, simple

nursing interventions

can alter patients’ pain

experience and speed

their recovery.” Taylor,

Lillis and White pg.

1168.

2. “Common fears

include a loss of control

Short Term

Goal: Met;

pain was rated

at a 2 on a

scale of 0 to 10

after

administration

of Vicodin.

to alleviate anxiety and

fears.

3. Educate the client on

her responsibility to

honestly report pain

when it occurs as well

as reporting if the

current pain

management is

effective or ineffective

for providing her pain

relief

4. Provide for

alternative/complement

ary measures of pain

relief, such as, reduce

lighting and noise,

soothing music, pet

therapy, massage, and

hot/cold packs

according to client

preferences.

and embarrassment by

being unable to deal

with pain maturely…

The patient may view

the need of for

medication as a sign of

weakness or may fear

addiction or loss of

effectiveness at a later

date.” Taylor, Lillis and

White pg. 1169.

3. “As a patient

advocate, ensure that a

strong emphasis on the

need for aggressive,

individualized strategies

that can minimize or

eliminate acute pain and

improve patient

outcomes. Preventing

pain is easier then

treating it once after it

occurs.” Taylor, Lillis

and White pg. 1178.

4.

Alternative/complement

ary measures will

provide an added benefit

of distraction from pain

experience and augment

analgesic effect.

Cold/hot therapy can

provide constriction and

or dilation which will

reduce pain

inflammation in each

specific circumstance

Daniels. Pg 378

Long Term

Goal. In

progress

OBJECTIVE

DATA:

Alert and

oriented 70

year old

widowed

female. Lives

in an

apartment

independently.

2 daughter live

nearby and

visit often.

History of a

fall while out

shopping 1 ½

weeks ago.

Right hip

surgically

repaired 7

days ago.

Surgical

dressing to

right hip is

clean, dry and

intact.

Circulation,

motion and

sensation

intact to right

lower

extremity.

Afebrile; BP

124/80; R-18

AP 84 and

regular. 5 foot

7 inches

weighs 142

pounds. No

hearing

deficits; wears

eye glasses

LONG

TERM:

Client will

report pain

level of 2 or

less using

ibuprofen

with

alternative

pain control

methods by

discharge.

Medical

history

positive for

osteoarthritis

and

osteoporosis

Non weight

bearing to

right leg and

to use a

walker for

ambulation

To start

physical

therapy for

gait and

strength

training BID

times 7 days

and

occupational

therapy to

develop upper

body strength

once daily

times 7 days

Reports pain

level is at 8 on

a scale of 0 to

10.

Has Vicodin

5mg/325 mg

po 2 tabs

every 4 hours

prn for severe

pain

Ibuprofen 400

mg every 6

hours prn for

moderate pain.

Short term outcome: An outcome that can be accomplished by the end of the student clinical day.

Interventions: Each nursing intervention must come from a reliable nursing reference or source.

Please note: do not use nursing care planning book exclusively. Not more than one

intervention can come from a source outside your textbooks.

Rationales: Cite a reliable source for each intervention (name of text, author, page number,

internet site and date retrieved (reliable sites: .gov or .edu. or .org)

NANDA DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED

BY STATEMENT:

ASSESSMENT

(Data that directly

pertains to the

above nursing

diagnosis)

OUTCOME

STATEMENT

(Patient centered,

realistic, specific,

measurable,

target time)

INTERVENTIONS

(Individualized,

specific, frequency)

SCIENTIFIC

RATIONALE

(Supporting

statement from

text or other

source, cite

source)

EVALUATION

OF OUTCOME

(Met, partially

met, unmet,

unknown by

target time)

SUBJECTIVE

DATA: SHORT TERM:

OBJECTIVE

DATA: LONG TERM:

Short term outcome: An outcome that can be accomplished by the end of the student clinical day.

Interventions: Each nursing intervention must come from a reliable nursing reference or source.

Please note: do not use nursing care planning book exclusively. Not more than one

intervention can come from a source outside your textbooks.

Rationales: Cite a reliable source for each intervention (name of text, author, page number,

internet site and date retrieved (reliable sites: .gov or .edu. or .org)

...../30

NANDA DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED

BY STATEMENT:

ASSESSMENT

(Data that directly

pertains to the

above nursing

diagnosis)

OUTCOME

STATEMENT

(Patient centered,

realistic, specific,

measurable,

target time)

INTERVENTIONS

(Individualized,

specific, frequency)

SCIENTIFIC

RATIONALE

(Supporting

statement from

text or other

source, cite

source)

EVALUATION

OF OUTCOME

(Met, partially

met, unmet,

unknown by

target time)

SUBJECTIVE

DATA: SHORT TERM:

OBJECTIVE

DATA: LONG TERM:

Short term outcome: An outcome that can be accomplished by the end of the student clinical day.

Interventions: Each nursing intervention must come from a reliable nursing reference or source. .

Please note: do not use nursing care planning book exclusively. Not more than one

intervention can come from a source outside your textbooks.

Rationales: Cite a reliable source for each intervention (name of text, author, page number,

internet site and date retrieved (reliable sites: .gov or .edu. or .org)

..../30

NANDA DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED

BY STATEMENT:

ASSESSMENT

(Data that directly

pertains to the

OUTCOME

STATEMENT

INTERVENTIONS

(Individualized,

specific, frequency)

SCIENTIFIC

RATIONALE

EVALUATION

OF OUTCOME

above nursing

diagnosis)

(Patient centered,

realistic, specific,

measurable,

target time)

(Supporting

statement from

text or other

source, cite

source)

(Met, partially

met, unmet,

unknown by

target time)

SUBJECTIVE

DATA: SHORT TERM:

OBJECTIVE

DATA: LONG TERM:

Short term outcome: An outcome that can be accomplished by the end of the student clinical day.

Interventions: Each nursing intervention must come from a reliable nursing reference or source. .

Please note: do not use nursing care planning book exclusively. Not more than one

intervention can come from a source outside your textbooks.

Rationales: Cite a reliable source for each intervention (name of text, author, page number,

internet site and date retrieved (reliable sites: .gov or .edu. or .org)

................/30

Key Problem: Impaired urinary elimination

Data:

Intake=3800 Output=3200

Polyuria

3+ glucose in urine

AEB: Polydipsia and polyuria

Outcomes:

Pt. will have urine output of 1000 – 2000 ml/24 hours.

Interventions:

Monitor I & O q shift.

Monitor BGM a.c. and h.s.

Monitor kidney function tests

Administer antihyperglycemics as ordered.

Key Problem: Knowledge deficit

Data: Pt verbalizes confusion about diagnosis, new meds, diet, exercise routine

AEB: Verbal statements and questions.

Outcomes:

Pt will verbalize understanding of ADA diet and administer insulin using appropriate technique

by discharge.

Interventions:

Assess level of knowledge regarding diabetes/ treatment and client’s preferred learning style.

Provide information q shift according to teaching plan recorded in EMR and document pt’s

response.

Reassess level of knowledge daily.

Provide written information.

Provide educational resources available in the community.

Medical Problems (Pathophysiology)/Surgical Procedures:

Newly diagnosed diabetic

Key Assessments:

S/S of hyper and hypoglycemia, good intake, I/O, glucose level, vitals

Tests: FBS, hemoglobin A1C

“I don’t know how this fits”

Recent widow

Kids live out of state

? support system

Key Problem: Acute anxiety

Data: Restless, verbally states she is anxious.

AEB: Pt states “I don’t know what I will do with diabetes, this is too much.”

Outcomes: Pt. will verbalize under-standing of resources available by discharge.

Interventions:

Provide pt. with an opportunity each shift to verbalize anxiety by asking open ended questions.

Demonstrate progressive relaxation exercises and have pt. return demonstrate.

Provide pt. with a list of community resources for newly diagnosed diabetics.

Identify client’s perception of anxiety

Utilize empathy.

Past Medical History: Hypertension x 20 years; appendectomy at age 9.

Risk Factors: Mother had Type 2 diabetes; hypertension; Native American descent; sedentary

lifestyle; 290 pounds, age 52

Key Problem:

Imbalanced nutrition, more than

Data:

BMI: 35.0–39.9; Ht: 5”9; Wt: 290 lbs

AEB: Anthropometric measurements.

Outcomes: Client will verbalize a realistic weight loss goal and three strategies to reach it prior

to discharge.

Interventions:

Assess client’s knowledge of nutrition and its relationship to diabetes.

Arrange for dietary consultation.

Reinforce teaching by dietician.

Encourage physical activity as a weight loss strategy.

Provide pt with community resources that can assist her with weight loss goal.

“I DON’T KNOW HOW THIS FITS”

PAST MEDICAL HISTORY

RISK FACTORS

MEDICAL PROBLEMS (PATHOPHYSIOLOGY)/SURGICAL PROCEDURES:

KEY ASSESSMENTS:

Key Assessments:

Tests:

KEY PROBLEM:

DATA:

AEB:

OUTCOMES:

INTERVENTIONS:

KEY PROBLEM:

DATA:

AEB:

OUTCOMES:

INTERVENTIONS:

RUBRIC for Grading Packets

/60pts

KEY PROBLEM:

DATA:

AEB:

OUTCOMES:

INTERVENTIONS:

KEY PROBLEM:

DATA:

AEB:

OUTCOMES:

INTERVENTIONS:

Student Name: Clinical Date: Site:

Section Grading Criteria Satisfactory Or

Unsatisfactory

Comments,

Kudos,

Things to

Improve for

Next Time

10 points

Patient Demographics,

Diagnoses, Surgeries,

Orders, Rehab, IV,

Imaging and Lab

Page 1 fully and correctly

completed 5 pts

Page 2 fully and correctly

completed 5 pts

_/5___

_/5___

20 points

Medications

Medication Trade Name 2 pts

Medication Generic Name 2 pts

Pharmacological Classification 2

pts

Normal Dosage Range 2 pts

Dose ordered 2 pts

Route and Frequency 2 pts

Contraindications 2 pts

Adverse Effects/Reactions 2 pts

Nursing Considerations & Teaching

2 pts

(Legible or typed) 2 pts

/ 2

/ 2

/ 2

/ 2

/ 2

/ 2

/ 2

/ 2

/ 2

/ 2

_/20__

10 points

Narrative Notes

Head-to-Toe

Assessment

Narrative note is in Head to Toe

order

Head-to-toe assessment

documented Abnormal results

noted 10 pts Nursing Care Plan and

Diagnosis for Chronic Pain

___/10_

60 points (either a

Concept Map or a

Patient Care Plan)

Concept Map

Correct Medical Diagnosis 15 pts

Pathophysiology 15 pts

Key Assessments 15 pts

____/60

OR

At least 3 problems identified 15

pts

Nursing Care Plan and Diagnosis

for Chronic Pain

60 points (either a

Concept Map or a

Patient Care Plan)

Patient Care Plan

3 nursing diagnoses Related to”

“As evidenced by” 18 pts

2 Outcomes specific, measurable,

timed 8 pts

4-5 Interventions are logical,

appropriate 15 pts

4-5 Scientific Rationales supporting

each intervention 15 pts 2

Evaluations 4 pts