Plan of Care

October 6, 2020 Plan of Care NURSING DIAGNOSIS GOAL EXPECTED OUTCOMES Impaired Comfort r/t lack of Client will have improved relief of neck pain secondary comfort in 7 days AEB to anxiety AEB Client will state pain level ASSESSMENT DATA at 1 or 2 within 30 minutes (Subjective & Objective) of analgesics given by day 3 post-op Subjective: “This pain is stabbing Client will be able to and sharp; I just can’t move in chair and not get comfortable” grimace by day 2 post-op “I just want to go home; I can be more Client will describe how comfortable there” to manage pain by re“I haven’t slept since evaluation Q24H yesterday and I think it was only for like an Client will have vital signs hour” within normal limits by “Is it time for my post-op day 3 Q4H. pain medications; I’m in a lot of pain?” Client will participate in a “I just want relief” therapeutic regimen such “I need to get home; as yoga, meditation, or right before surgery guided imagery 3 times a my babysitter week. cancelled, and my 14year-old is looking Client will have improved after my other mood and coping within 7 children. It’s not her days. INTERVENTIONS 1. Ask client about current level of comfort Q4H every shift. 2. Encourage mobilization and provide routine position changes, and ROM exercises at least once per shift. 3. Encourage and teach relaxation techniques to reduce pain, anxiety, depression, and fatigue Qshift such as: deep breathing, meditation, yoga, aromatherapy. 4. Administer pain medications such as: Hydromorph one PO 2mg Q4H PRN Lorazepam RATIONALE WITH REFERENCE 1.Sources of assessment data to determine level of comfort can be subjective, objective, primary or secondary [ CITATION Ack2011 \l 1033 ] 2.Has been shown that immobility is linked to many unacceptable patient outcomes in critical care units [ CITATION Ack2011 \l 1033 ] 3.Quantitative study with 22 participants, the effects of traditional massage and cranial still point induction were statistically significant in EVALUATION October 6, 2020 responsibility; it’s Client will be able to sleep mine” for at least 4 hours Qshift. “I am the one who does everything around the house; even grocery shopping and now I don’t know who is going to do it” “I’m going to go for a walk is that okay? I believe it will make me feel better” Rates pain 8/10 on scale 0-10 Objective: Pain 8/10 on pain scale VS: T 99.2, R 32, P 108 Respirations irregular and fast Constantly moving around in bed or chair while trying to have conversation Constantly pulling at C-collar while sitting Groans and moans while in chair as well as walking the halls Fidgets with fingers while talking Avoids eye contact 0.5mg PO Q6H PRN Ondanetron 4mg IV Q8H PRN Hydroxyzine 25mg PO Q6H PRN Morphine 2mg IV Q2H PRN 5. Assess client for pain on scale of 010, intensity, location, and characteristics before administration of medications as well as PRN during shift. improving comfort and decreasing chronic pain [ CITATION Ack2011 \l 1033 ] 4.If pain is present for most of the day, the use of PRN medications will lead to periods of undermedication and poor pain control as well as periods of excessive medication and adverse effects [ CITATION Ack207 \l 1033 ] 7. Use guided imagery to decrease anxiety at least 3 times per week. 5.Determining location, temporal aspects, intensity, characteristics and effects of pain on function and quality of life are critical to determine the underlying cause of pain and effectiveness [ CITATION Ack207 \l 1033 ] 8. Assess how much 6.Systematic tracking 6. Reassess client for presence of pain and response to pain management at least 3 times per shift or PRN. October 6, 2020 occasionally Patient has tears in her eyes while communicating Facial grimacing when moving time the client spends in bed unable to sleep and client’s comfort level with low sleep efficiency Qshift. of pain is an important factor in improving pain management and adjusting the pain management regimen [ CITATION Ack207 \l 1033 ] 7.Guided imagery can be utilized to aid patients in handling undesirable emotions connected with the symptoms of their illness [ CITATION Ack205 \l 1033 ] 8.Meta-analysis of results representing 5061 generalpopulation adults showed a steady increase after age 50 in amount of time set aside for nighttime sleep, which contributed to steady decline in sleep efficiency over life span [ CITATION Ack2012 \l 1033 ]