Free Acute Pain Nursing Care Plan Template
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
-
Instruction: Educate the patient on the importance of reporting pain regularly and using the pain scale for accurate reporting.
-
Rationale: Encourages self-management and ensures timely interventions.
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
