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 GENDER :

ADMISSIO N DATE:

CODE STATUS: ALLERGIES: MARITAL STATUS:

OCCUPATIO N (FORMER):

MEDICAL DX: CHIEF COMPLAINT :

PAST HISTORY (SURGERY/PROCEDURE S) 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 TREATMEN T PLAN & SCHEDULE

RATIONAL E

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 Adverse Reactions

Frequency

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 SHORT 1. Educate the client on 1. “There are many ways Short Term

DATA: “My right hip hurts me so much every time I move. I am so afraid to start physical therapy”

TERM: Client will report pain level rated at a 3 or lower 30 minutes after pain medication taken

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 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

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 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.

Goal: Met; pain was rated at a 2 on a scale of 0 to 10 after administration of Vicodin.

Long Term Goal. In progress

preferences.

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

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

LONG TERM: Client will report pain level of 2 or less using ibuprofen with alternative pain control methods by discharge.

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

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 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

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

At least 3 problems identified 15 pts

Nursing Care Plan and Diagnosis for Chronic Pain

____/60

OR

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

Nursing Care Plan for Pain with Diagnosis and Nursing Intervention

Nursing Care Plan for Pain with Diagnosis and Nursing Intervention

Pain classifications Acute pain:

Mild to severe pain lasting less than six months; associated with a sympathetic nervous system response; resulting in increased pulse rate and volume, increased respiratory rate and depth, increased blood pressure, and increased glucose levels; decreased urine production and peristalsis.

The protective function of acute pain is to alert the patient of injury or infection. The onset of sudden severe pain prompts the patient to seek solace. The physiological manifestations of acute pain result from the body's tension response to the pain. Acute pain may be exacerbated by the patient's cultural context, emotions, and psychological or spiritual distress. The assessment of pain can be challenging, particularly in elderly patients with cognitive impairment and sensory

perception deficits. Chronic ache:

Mild to severe pain lasting longer than six months; associated with the parasympathetic nervous system; the patient may not exhibit acute pain-related signs and symptoms. may result in despondency and diminished function

Terms for suffering

Pain threshold is the minimum quantity of stimulus required to produce a painful sensation. The maximum quantity of pain that a patient is willing or able to tolerate. Pain felt in a location other than the origin of a tissue injury Pain that cannot be relieved by conventional treatments is untreatable. Neuropathic pain: agony caused by a neurological disorder and unrelated to tissue damage Phantom pain: pain felt in an absent body part Radiating pain: pain felt at the source that spreads to other locations.

[caption id="attachment_15455" align="alignright" width="345"] Nursing Care Plan and Nursing Intervention[/caption]

Plan of nursing care for pain that includes intervention and pain

Affiliated with suffering

medical concerns Diagnostic techniques and medical care emotionally and mentally traumatic Aspirational Cultural distress.

Desired Results

On a scale from 0 to 10, the patient reports adequate pain control with a score of less than 3 to 4. The patient is capable of utilizing both pharmacologic and nonpharmacologic pain relief strategies. Patient feels more at ease, as demonstrated by a regulated pulse, blood pressure, respiration, and calm muscle tension and posture.

May be exemplified by.

Protective behavior, body protection, egocentric, narrowed focus Relief or diversion methods

Pain masking the face Consideration of muscular tone

Nursing care plan for pain with intervention and rationale

Nursing intervention Rationale

Assessment of pain characteristics. ex. Quality, severity, location, onset, duration, precipitating and relieving factors

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.

Screening for signs and symptoms related to pain.

Some people deny the sensation of pain even though it is present. Paying attention to signs associated with pain can help the nurse assess pain. A patient with acute pain may have elevated blood pressure, heart rate, temperature, be agitated, and have difficulty concentrating.

For scientific findings and symptoms associated with chronic pain, such as fatigue, decreased appetite, weight loss, change in posture, disruption of sleep patterns, anxiety, agitation, or depression.

Patients with chronic pain may not exhibit the physical changes and behaviors associated with acute pain. Pulse and blood pressure are usually within the normal range.

Evaluate the patient’s response to pain and pain management strategies.

It is important to assist the patient in presenting the effect of pain-relieving measures as factually as possible. Discrepancies between the patient’s behavior or demeanor and what he or she says about pain relief.

Assess patient’s expectations for pain relief.

Some patients are satisfied with pain relief, while others expect complete elimination of pain, which affects their perception of the effectiveness of the treatment method and their willingness to participate in further treatment.

Anticipate the need for pain relief. The most effective way to address pain is to prevent it. Early intervention can reduce the total amount of analgesics needed.

Eliminate additional stressors or discomfort whenever possible.

Patients may experience exaggeration of pain or diminished ability to tolerate painful stimuli if they experience additional stress from environmental, intrapersonal, or intrapsychic factors.

Provide rest periods to promote comfort, sleep, and relaxation.

The patient’s perception of pain may be exaggerated by fatigue. In a cycle, pain can lead to fatigue, which in turn can lead to exaggerated pain and fatigue. A quiet environment, a darkened room, and a phone turned off are measures that facilitate recovery.

Determine the appropriate method for pain relief.

Unless contraindicated, all patients with acute pain should receive a nonopioid analgesic around the

clock.

Hot or cold compress

Heat reduces pain by improving blood flow to the area and reducing pain reflexes. Cold reduces pain, inflammation, and spastic massage by decreasing the release of pain-inducing chemicals and slowing the transmission of pain impulses.

Massage of the painful area Increases endorphin levels and decreases tissue edema. This intervention may require another person to perform the massage.

Administer analgesics as ordered by a physician, evaluate their effectiveness, and observe signs and symptoms of side effects.

Analgesics are absorbed and metabolized differently by patients, so their effectiveness must be assessed by the patient individually. Analgesics usually have side effects that range from mild to life-threatening.

Notify the physician if interventions are unsuccessful or if current symptoms represent a marked change from the patient’s previous pain experience.

Patients who request pain medications at shorter intervals than prescribed may actually require a higher dose or stronger analgesics.

Anticipatory education about the causes of pain and appropriate measures for prevention and relief.

Knowing what to expect can help patients develop effective coping strategies for pain management. Patients need to learn the importance of reporting pain early to achieve more effective pain relief.

The patient should learn how to effectively discontinue the medication dose in relation to potentially unpleasant activities and avoidance of pain spikes.

Patients must learn to use pain relief strategies to minimize the pain experience.

Assist the patient and family in identifying lifestyle changes that can contribute to effective pain management. Guide the patient to plan activities during the times when pain is at its greatest relief.

Changes in work routine, household responsibilities, and home environment may be necessary to promote more effective pain management. Ongoing support and guidance for the patient and family will increase the success of these strategies.

How to Write a Nursing Care Plan How to Write a Nursing Care Plan

Nursing Care Plan Components A nursing care plan has several key components including,

 Nursing diagnosis

 Expected outcome  Nursing interventions and rationales  Evaluation

Each of the five main components is essential to the overall nursing process and care plan. A properly written care plan must include these sections otherwise, it won’t make sense!

 Nursing diagnosis - A clinical judgment that helps nurses determine the plan of care for their patients

 Expected outcome - The measurable action for a patient to be achieved in a specific time frame.

 Nursing interventions and rationales - Actions to be taken to achieve expected outcomes and reasoning behind them.

 Evaluation - Determines the effectiveness of the nursing interventions and determines if expected outcomes are met within the time set.

How to Write a Nursing Care Plan Determine the patient's most significant issues prior to composing the nursing care plan. Consider both medical and psychosocial difficulties. At times, a patient's psychosocial concerns may be more pressing or even hold up his or her discharge than the patient's actual medical problems.

After compiling a list of the patient's issues and the corresponding nursing diagnosis, you must determine which are the most significant. In general, this is done by contemplating the ABCs (Airway, Breathing, Circulation). However, these won't ALWAYS be the most significant or even pertinent for your patient.

Step 1: Assessment

The first step in writing an organized care plan includes gathering subjective and objective data. Subjective data is what the patient tells us their symptoms are, including feelings, perceptions, and concerns. Objective data is observable and measurable.

This information can come from,

 Verbal statements from the patient and family  Vital signs

o Blood pressure o Heart rate o Respirations o Temperature o Oxygen Saturation

 Physical complaints o Pain o Headache

o Nausea o Vomiting

 Body conditions o Head-to-toe assessment findings

 Medical history  Height and weight  Intake and output  Patient feelings, concerns, perceptions  Laboratory data  Diagnostic testing

o Echocardiogram o X-Ray o EKG

Step 2: Diagnosis

Using the information and data gathered in Step 1, the nursing diagnosis that best suits the patient, his or her hospitalization goals and objectives is selected.

North American Nursing Diagnosis Association (NANDA) defines nursing diagnosis as "a clinical judgment about the human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community."

The nursing diagnosis is founded on Maslow's Hierarchy of Needs and assists with treatment prioritization. The next stage involves determining the goals for resolving the patient's problems through nursing interventions based on the nursing diagnosis selected.

There are 4 types of nursing diagnoses.

1. Problem-focused - Patient problem present during a nursing assessment is known as a problem-focused diagnosis

2. Risk - Risk factors require intervention from the nurse and healthcare team prior to a real problem developing

3. Health promotion - Improve the overall well-being of an individual, family, or community

4. Syndrome - A cluster of nursing diagnoses that occur in a pattern or can all be addressed through the same or similar nursing interventions

After determining which type of the four diagnoses you will use, start building out the nursing diagnosis statement.

The three main components of a nursing diagnosis are:

1. Problem and its definition - Patient’s current health problem and the nursing interventions needed to care for the patient.

2. Etiology or risk factors - Possible reasons for the problem or the conditions in which it developed

3. Defining characteristics or risk factors - Signs and symptoms that allow for applying a specific diagnostic label/used in the place of defining characteristics for risk nursing diagnosis

Examples:

PROBLEM-FOCUSED DIAGNOSIS

Problem-Focused Diagnosis related to ______________________ (Related Factors) as evidenced by _________________________ (Defining Characteristics).

RISK DIAGNOSIS

The correct statement for a NANDA-I nursing diagnosis would be: Risk for _____________ as evidenced by __________________________ (Risk Factors).

Step 3: Outcomes and Planning

After determining the nursing diagnosis, it is time to create a SMART goal based on evidence- based practices. SMART is an acronym that stands for,

 Specific  Measurable  Achievable  Relevant  Time-Bound

It is essential to take into account the patient's medical diagnosis, overall condition, and all collected data. A physician or other advanced healthcare professional makes a medical diagnosis. It is essential to remember that a medical diagnosis does not change if the patient's condition improves, and it remains a permanent part of the patient's medical history.

Examples of medical diagnosis include,

 Chronic Lung Disease (CLD)  Alzheimer’s Disease  Endocarditis  Plagiocephaly  Congenital Torticollis  Chronic Kidney Disease (CKD)

During this period, you will also consider the patient's goals and short- and long-term outcomes. These objectives must be achievable and desired by the patient. For instance, if a goal is for the

patient to seek counseling for alcoholism during hospitalization, but the patient is currently detoxifying and experiencing mental distress, this goal may not be achievable.

Step 4: Implementation

Now that the objectives have been established, you must take the necessary steps to assist the patient in achieving them. While some actions will produce immediate results (e.g., administering a suppository to a patient with constipation to induce a digestive movement), others may not be observed until later in the hospitalization.

The implementation phase means performing the nursing interventions outlined in the care plan. Interventions are classified into seven categories:

 Family  Behavioral  Physiological  Complex physiological  Community  Safety  Health system interventions

Some interventions will be patient or diagnosis-specific, but there are several that are completed each shift for every patient:

 Pain assessment  Position changes  Fall prevention  Providing cluster care  Infection control

Step 5: Evaluation

The fifth and final step of the nursing care plan is the evaluation phase. This is when you evaluate if the desired outcome has been met during the shift. There are three possible outcomes,

 Met  Ongoing  Not Met

On the basis of the evaluation, it can be determined whether the objectives and interventions need to be modified. Ideally, all nursing care plans, including objectives, should be met prior to discharge. This is not always true, particularly when a patient is being discharged to hospice, home care, or a long-term care facility. Initially, you will discover that the majority of care plans will have ongoing objectives that may be met within a few days or weeks. It depends on the patient's condition and the desired outcomes.

Consider selecting objectives that the patient is capable of achieving. This will not only help the patient feel as though they are making progress, but it will also relieve the nurse by allowing them to monitor the patient's overall progress.

Nursing Care Plan Fundamentals

Nursing care plans contain information about a patient’s diagnosis, goals of treatment, specific nursing interventions, and an evaluation plan. The nursing plan is constantly updated with changes and new subjective and objective data.

Key aspects of the care plan include,

 Assessment  Diagnosis  Outcome and Planning  Implementation  Evaluation

Through subjective and objective data, constantly assessing your patient’s physical and mental well-being, and the goals of the patient/family/healthcare team, a nursing care plan can be a helpful and powerful tool.

Evidence-Based Practice in Nursing

Examine the importance of incorporating current research evidence into clinical decision-

making and discuss the steps involved in implementing evidence-based practice in nursing care.

Evidence-based practice (EBP) in nursing is a systematic approach that integrates the best

available research evidence, clinical expertise, and patient preferences to guide clinical decision-

making and improve patient outcomes. It involves critically appraising and applying research

findings to inform nursing practice, ensuring that interventions and care are based on the most

up-to-date and reliable evidence. Here is a detailed explanation of evidence-based practice in

nursing:

1. Importance of Evidence-Based Practice:

 Enhancing Patient Outcomes: By incorporating current research evidence into

clinical decision-making, nurses can provide care that is more effective, safe, and

aligned with best practices, leading to improved patient outcomes.

 Ensuring Quality and Safety: Evidence-based practice promotes the use of

interventions and procedures that have been shown to be safe and effective

through rigorous research. This reduces the risk of harm to patients and enhances

the overall quality and safety of nursing care.

 Advancing Professional Development: Engaging in evidence-based practice

encourages nurses to stay updated with the latest research findings, enhancing

their knowledge and professional growth. It also fosters a culture of lifelong

learning within the nursing profession.

2. Steps in Implementing Evidence-Based Practice:

 Formulating a Clinical Question: The first step in evidence-based practice is

formulating a clear and focused clinical question based on the patient's problem or

the nursing intervention under consideration. The question should be structured

using the PICO framework (Population, Intervention, Comparison, Outcome) to

guide the search for relevant evidence.

 Conducting a Literature Search: Once the clinical question is identified, nurses

conduct a systematic search of the literature using databases and other reliable

sources to find relevant research evidence. This includes peer-reviewed journals,

systematic reviews, meta-analyses, and clinical practice guidelines.

 Appraising the Evidence: After identifying relevant research articles, nurses

critically appraise the evidence to evaluate its validity, relevance, and

applicability to the clinical question. This involves assessing the study design,

sample size, methodology, and statistical analysis to determine the quality and

strength of the evidence.

 Synthesizing the Evidence: Nurses analyze and synthesize the findings from

multiple research studies to develop a comprehensive understanding of the

evidence. This includes comparing and contrasting the results, identifying patterns

or consistencies, and determining the overall strength of the evidence.

 Integrating the Evidence: Based on the synthesis of the evidence, nurses integrate

the findings into their clinical decision-making process. They consider the

patient's unique circumstances, preferences, and values, along with their own

clinical expertise, to develop an individualized care plan.

 Evaluating Outcomes: Nurses implement the evidence-based intervention and

closely monitor the patient's response. They collect data on outcomes, evaluate

the effectiveness of the intervention, and make adjustments as necessary. This

step contributes to the ongoing cycle of evidence-based practice, as outcomes are

assessed and used to inform future practice decisions.

3. Barriers and Facilitators of Evidence-Based Practice:

 Barriers: Some common barriers to implementing evidence-based practice in

nursing include time constraints, lack of access to research literature, limited

skills in critically appraising research, resistance to change, and organizational

culture that does not prioritize evidence-based practice.

 Facilitators: Organizations can support evidence-based practice by providing

resources, promoting a culture of inquiry, and offering training and mentorship to

nurses. Collaboration between nurses, researchers, and educators can also

facilitate the integration of research evidence into practice.

4. Ethical Considerations: Nurses must consider ethical principles when implementing

evidence-based practice. This includes obtaining informed consent from patients,

ensuring patient confidentiality, respecting patient autonomy, and considering the

potential risks and benefits of interventions based on the available evidence.

Evidence-based practice is a continuous process that requires ongoing learning, critical thinking,

and integration of research findings into nursing practice. By incorporating