Care Plan Assessment Nursing Diagnosis Objectives Interventions Rationales Evaluations

S- Age 56 y/o S- Admitting Dx: perforated appendicitis S- Hx: Pancreatitis S- Drainage of ABD abscess on 9/26/2011 S- S/P Exploratory Laparotomy on 9/29/2011 S- S/P appendectomy on 9/29/2011 S- Patient states pain level of 7 on a scale of 0-10 S- Patient statesYeah, that hurts upon palpation

Acute pain R/T abdominal surgical incisions AEB subjective reports of pain of a 7 on a scale of 0-10.

1.Assess patient every 2 hrs. for pain

This was successful. I was unable to enter the patients room for a consistent every two hours, however. To modify this I assessed the patients pain every time I entered or left the patients room. A.A rating scale is the most reliable method for assessing pain severity (Williams, Hopper, p. 158, 2011).

A. Assess pain level in the patient by using a self-report pain tool such as 0-10 pain rating tool.

This tool was effective to successfully identify the patients pain level. No modifications were needed.

Care Plan near surgical incision O- LOC: AAO x 3; patient accurately states name, DOB, and knows that he is in the hospital. O: JP tube x 2; L and R O: Surgical incision wound on lower abdomen midline O: Peripheral IV # 77 in LFA Piperacil/Tazobac 50 Ml begin 0545 09/29/2011 O: Peripheral IV # 114 in LFA KCl 1000 mL begin 1815 09/30/2011 O: Other meds administered: enoxaparin, famotidine, and 2. Use pain control measures as needed before activities that will entice pain in the patient B. Observe for grimacing irritability, reluctance to move or inability to lie quietly

B. Non-verbal cues are helpful in recognizing the presence of pain (Doenges, Moorhouse, & Murr, 2010, p. 577)

I watched for non-verbal cues as I was in contact with the patient to be sure that he was not masking his pain. His grimaces and pain rating of 7s were helpful in identifying his pain and subsequently providing treatment. This was successful and did not need modifications.

Effective pain management maximizes the patients ability to tolerate or participate in procedures such as bathing and ambulation (Williams & Hopper, 2011, p. 579).

This intervention was successful and useful in preventing worsened pain in the patient. After pain control measures he was more

Care Plan hydromorphone O: Patient exhibits full gross and fine motor control willing to bath and ambulate because he was not in much pain. It did not require any modifications except me informing his RNs of his need of medication before activity before I left the floor.

Short Term Objective 1: Patient will report a pain level of 2 or 3 within 30 minutes of their pain report Short Term Objective 2: Patient will express the need for pain control measures every time prior to receiving wound care, ambulation, or before performing ADLs A. Administer analgesics to the maximum dose before pain becomes severe as ordered by the physician A. The administration of analgesics before a pain producing event helps to minimized the pain that will Be experienced. They are more effective if given before pain becomes severe because mild to moderate pain is controlled more quickly and effectively than severe pain (Williams & Hopper, 2011, p. 53). And The type of medicine ordered depends on the severity of the pain. Acetometophin and NSAIDs are commonly used to treat mild to moderate pain,

I did not administer his pain medication because it was prn and was given IV by the nurse. I modified this by watching the nurse give the patient his medication. The medication was given in a timely manner within 5-10

Care Plan Long Term Objective: Upon discharge the patient will be able to perform activities of recovery or ADLs easily with a pain level of 2. while opiates (morphine, oxycodone, and fentanyl) are used to treat moderate to severe pain (Williams & Hopper, 2011, p. 579). minutes of his request so this was a successful intervention

i. i. Hydromorphone by IV. 1 mg for pain scale 1-4

Hydromorphone reduces moderate pain by binding to opiate receptors in the CNS and altering the perception of painful stimuli while producing CNS depression.

This medication was not given because the patients reported pain was always over a 6 on a 010 scale. Distraction techniques were used for pain on the level of 1-4.

i. ii. Hydromorphone by IV. 2mg for pain scale 5-10

Hydromorphone reduces severe pain by binding to opiate receptors in the CNS and altering the perception of painful stimuli while producing CNS depression.

This medication was given every time the patient complained of pain in my care. He responded well to it, without any nausea or vomiting. His pain was

Care Plan reduced from a 7 to a 3 every time so the medication was successful B.Non-pharmacologic relaxation skills and techniques have no detrimental side effects (Doenges, Moorhouse, & Murr, 2010, p. 580) Nonpharmacologic techniques were used successfully by the patient. He used techniques such as breathing and distraction by watching TV and movies on his personal DVD player to reduce his pain. He used this technique when his pain level was between a 1 and 4. This did not need to be modified.

B. Encourage nonpharmacologic therapeutic techniques to help relieve pain i. ii. iii. Back rub Visualization Guided imagery

3. Evaluate adverse

3. Intolerable adverse symptoms require a change of

The patient did not appear to

Care Plan medication effects such as decreased mental activity, change in thought process, confusion, urine retention, nausea, vomiting, or puritis medications for the patient (Williams & Hopper, 2011, p. 580). have any adverse effects after medication administration in my care. He did not appear to have any decreased mental activity or confusion. He stated that he was not nauseous and did not vomit or itch. He seemed more relaxed after his pain medication was given.

4. Position patient in a semi-Fowlers position to promote comfort

4. A semi-fowlers position will decrease the tension on the abdomen and will reduce stress on the suture line (Williams & Hopper, 2011, p. 763)

The patient remained in a semi-Fowlers position while he was in the bed even as he rested. He stated that the position was most comfortable for him. This was successful and

Care Plan did not require modification. 5. Ambulation promotes an active role in preventing further pain due to muscle spasms or contractures and enhances sense of control (Williams & Hopper, 2011, p. 580).

5. Encourage performance of individual physical therapy or exercise programs such as ambulation

Patient enjoyed ambulation and even looked forward to it. He stated that he understood the importance of ambulation. He always requested pain medication before ambulation so that it would remain enjoyable to him. He was completely active in ADLs and only needed assistance to wash his legs and feet. This was successful and did not require modification.

Care Plan 6. Splinting will stabilize the site and reduce pain, this will increase the likelihood of deep breathing and coughing (Williams & Hopper, 2011, p. 676) The patient was well informed the importance of splinting and deep breathing exercises. He did not require a pillow to splint as he did his deep breathing exercises but did use a pillow to splint when I bathed his back. This was successful. He had been informed of this by all of his prior and current nurses

6. Teach patient the importance of splinting his abdomen when performing necessary deep breathing exercises and coughing

A. Inform the patient and his family why it is necessary to deep breath despite pain

A. Deep breathing and coughing after surgical procedures helps prevent atelectasis and respiratory tract infections (Williams & Hopper, 2011, p. 763).

The patient and his sister understood that although deep breathing may be painful it was necessary expand his lungs. His sister said that she

Care Plan would continue to encourage her brother to deep breath. This was successful and did not require any modification because the patient and his sister had been informed of this many times

B. Show the patient how to splint the abdominal incision by using his hands or a pillow

B. Using a pillow to splint will ease the discomfort of coughing and taking deep breaths (Gulanick & Myers, 2011, p. 553).

The patient was informed by his RNs how to use a pillow to splint after he was admitted on the floor. He was well aware how to use it and said it was useful when he was being bathed but not for deep breathing. This was successful and did not require

Care Plan modification. C. Incentive spirometry encourages deep breathing, and allows for full expansion of the alveoli (Gulanick & Myers, 2011, p. 553).

C. Encourage the patient to use his incentive spirometer 10 times every hour

The patient was informed on the benefits of the incentive spirometer by all of his RNs and me. He was able to show me how to use it and express to me why it is useful. I do not think my patient used it as much as he should. Every time I came into his room while he was watching TV I would ask him if he had been using it and he said he hadnt since the last time I asked. He would then do it in front of me. To modify this I asked his RNs

Care Plan to remind him to use his spirometer because he would forget.

Short Term Objective 1: Patient will report a pain level of 2 - 3 within 30 minutes of their pain report

STO 1 This short term objective was met. He was administered his pain medication by his RN within ten minutes after he requested pain medication. He rated his pain a 7 before analgesic administration and a 3 thirty minutes after administration. I believe that this objective was appropriate for my patients

Care Plan situation. I knew that it would be unrealistic to expect his abdominal pain to be reduced to less than a pain scale of two. So I believe that a target goal of a 3 on the pain scale was realistic and appropriate for my patients post- surgical abdominal pain. I did not need any modifications. I did everything that I was capable of doing in this situation by reporting his pain to his attending RN immediately and watching her administer the analgesic.

Care Plan Short Term Objective 2: Patient will express the need for pain control measures, everytime, 30 minutes prior to receiving wound care, ambulation, or before performing ADLs STO 2 This goal was met. The patient was consistent in requesting pain medication before activities that caused him pain. He requested medication before activities such as walking to the bathroom to defecate because he said the strain of sitting caused him pain in his abdomen. He also requested pain medication before ambulating, sitting up in his chair, and bathing. He said that bending over while his nurses washed his back or bending to wash or put socks on

Care Plan his feet caused his pain to intensify. I offered to wash his back and his feet for him as well as put on his socks. I believe that this outcome is appropriate because requesting pain medication before activity will benefit him by reducing his pain. I also believe this Outcome is realistic for my patient. To modify my outcome I informed his RNs before I left the unit, that he would be ambulating soon and that he would be needing pain medication

Care Plan before he started. LTO This outcome was not yet because I was not there for his discharge. I believe, however, that this long term goal will be met. The patient has been progressing very well. By my second shift my patient had reduced signs of pain. He requested pain medication less frequently as the first day, only requesting it before ambulation. I believe that if he is consistent in telling his attending RNs about his pain

Long Term Objective: Upon discharge the patient will be able to perform activities of recovery or ADLs easily with a pain level of 2.

Care Plan before it reaches a severe level he will be able to keep his pain at low level of 2. Because of the previous statement, I believe that the goal is realistic and appropriate for my patients specific pain. This goal was modified by informing his RNs of my long term goal for him. They also agreed that it is an appropriate and realistic goal. The patient may also be prescribed a pain medication at discharge for use at home to keep his pain controlled.

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