Chronic Pain Care Plan

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Care Plan for Pain: Chronic|

Student Name:|Samantha Lewis|Current Date: 4/19/12||
Patient:|SL|Age: |33|Sex:|F|Dates Care Given: 4/19/2012||

Admission Diagnosis/History: Chronic Pancreatitis|
1)PE 2) Hysterectomy 3)C Section |

Nursing Diagnosis: Pain: Chronic |
|

ASSESSMENT|
Objective Data|Subjective Data|
· Increased blood pressure|· Pt holding lower left abdomen|
· Increased heart rate|· Pt eyes closed|
· Increased respirations|· Furrowed brow|
· |· |
· |· |

Potential Complications: Drug dependence; addiction to opoids|
|

GOALS|
Expected Outcome|Outcome Criteria|TD|DA|
Patient will use a self-report pain tool to identify current pain level and establish a comfort-function goal.|Patient will identify and establish a comfort-function goal.|4/19||
Patient will perform necessary or desired activities at a pain level less than or equal to the comfort-function goal.|Patient will ambulate in hall atleast one time per day.|4/19||
Patient will describe how unrelieved pain will be managed.|Patient will verbalize and demonstrate an understanding of non-pharmacological pain management techniques.|4/19||
||4/5||
||||
TD: Target Date DA: Date Achieved

NURSING INTERVENTIONS|
Interventions|Rationale|
Assess the pain level in a client using a valid and reliable self-report pain tool. |Single dimension pain ratings are valid and reliable as measures of pain intensity level. (Breivik at al, 2008)|
Assess the client for pain presence using non verbal ques, and at frequent intervals.|Routine monitoring of the effects of the pain management regime results in improved pain management. (Layman-Young, Horton & Davidhizar, 2006)|
Teach non-pharmacological methods to decrease pain left unrelieved by pharmacologic methods.|Non-pharmacologic methods of pain relief such as distraction, position changes, massage and focused breathing are effective methods in relieving pain. (Layman-Young, Horton & Davidhizar, 2006)|
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