Acute Pain Nursing Care Plan
Patient Information
Patient Name | Age | Gender | Diagnosis | Date of Admission |
|---|
Gino Rohan | 45 | Male | Acute Post-Surgical Pain | November 20, 2050 |
Nursing Diagnosis
Acute Pain related to post-surgical tissue injury as evidenced by patient’s verbal report of pain intensity 7/10, restlessness, and guarding of surgical site.
Goal(s)
Short-Term Goal: The patient will report a decrease in pain intensity to 4/10 within 2 hours of intervention.
Long-Term Goal: The patient will experience pain relief and demonstrate comfort in daily activities within 48 hours.
Nursing Interventions
Intervention | Rationale | Frequency |
|---|
Assess pain level using a numerical rating scale (0-10) every 2 hours. | To evaluate the patient’s pain level and adjust interventions accordingly. | Every 2 hours |
Administer prescribed analgesics (e.g., Morphine 4 mg IV) as ordered. | To reduce the severity of pain through pharmacological intervention. | As needed |
Encourage deep breathing exercises every 1 hour while awake. | To help the patient relax and reduce muscle tension, which may alleviate pain. | Every 1 hour |
Provide a comfortable environment (adjusting pillows, maintaining a quiet room). | To promote physical comfort and reduce environmental factors contributing to pain. | Every shift |
Evaluation
Date | Goal Achieved? | Pain Rating | Interventions Adjusted |
|---|
November 21, 2050 | Yes | 4/10 | Increased frequency of deep breathing exercises to reduce anxiety. |
November 22, 2050 | Yes | 2/10 | Reduced analgesic dosage, continued deep breathing and relaxation techniques. |
Patient Education
Discharge Plan
Date | Discharge Plan |
|---|
November 23, 2050 | Pain management plan including at-home analgesics and follow-up appointment with surgeon. |
Prepared by: [YOUR NAME]
Email: [YOUR EMAIL]
Date: November 21, 2050
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