Pain Care Plan for Nursing
Care Plan Assignment
Directions:
Develop a care plan for ACUTE PAIN that includes the following:
· Problem identification
· Short term goal
· Long term goal
· 5 interventions/action with a rational for each intervention. State if the intervention is independent, interdependent or dependent. Make sure to have at least one of each for this assignment
· Also discuss how you would evaluate the short term goal, long term goal, and interventions
Patient
Mr. Gordon, a 52 year-old client who was admitted to the hospital following an MVC (motor vehicle crash). He suffered rib fractures and has a laceration along his right thigh. Mr. Gordon states that his pain is 9 on a 0 - 10 scale (0 being no pain, 10 being the worst). In addition his vital signs are: BP 150/88, HR 105, RR 22, SpO2 95% on RA (room air), T 98.6 degrees Fahrenheit taken orally.
Care Plan Grading Rubric
|
Topic |
Points Possible |
Points Awarded |
|
Problem |
1 |
|
|
Short term goal |
1 |
|
|
Short term evaluation (met or not and rational) |
1 |
|
|
Long term goal |
1 |
|
|
Long term evaluation (met or not and rational) |
1 |
|
|
Nursing interventions (5 total, appropriate for meeting goal) |
5 |
|
|
Nursing Rationales (5 total, appropriately related to intervention) |
5 |
|
|
Evaluation of Intervention effectiveness |
5 |
|
|
Total: |
20 |
|
|
Problem Identification: |
||
|
Short Term goal: (need a measureable timeframe):
|
Evaluation of Short Term goal: (met, not met, or partially met AND evaluation) |
|
|
Long-term goal: (needs a measureable time frame and will take longer to complete than the short term goal)
|
Evaluation of Long Term Goal: (met, not met, or partially met AND evaluation) |
|
|
Nursing Outcome Criteria: |
List five nursing interventions and rationale for each. State if intervention is dependent (D), independent (I), or interdependent (ID). (Cite source for rationales): |
Evaluation of effectiveness of intervention as related to goals (appropriate or inappropriate, if inappropriate make appropriate by either determining a new intervention or by rewriting to make appropriate) |
|
|
1. Intervention: Rationale:
2. Intervention: Rationale:
3. Intervention: Rationale:
4. Intervention: Rationale:
5. Intervention: Rationale:
|
1.
2.
3.
4.
5. |
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Resources: