Assessment Nursing Objectives Interventions Rationale evaluation

Diagnosis and goals

Objective Data: Risk for Goal:

After the nursing
• Post surgical infection related
intervention, the
Incision to post surgical client will be able to
• Narrowed incision experience Effectiveness:
minimized pain if Was the client able to:
focus (reduced
not totally relieved.
interaction 1. Report relief that
with people Reassure patient that you know pain is SOR: pain is accepted as
1. Report relief
and that pain is real and will assist her in dealing with it. Fear that pain will real and that she will
environment) accepted as not be accepted as received assistant in
real and that real increases tension pain relief?
she will and anxiety and ___ met
Risk factors: decreases pain ___ partially met
received
• Environmental assistant in tolerance. ___ not met
factor Reference:
pain relief. Medical Surgical Nursing
• Decrease by Smeltzer and Bare, 10th
edition, Vol 1, p245
tissue
perfusion 2a. Describe the
• Decrease Perform comprehensive assessment: SOR: intensity of pain using
Ask the client to describe pain using 0-10 Provides baseline for 0-10 numeric pain
wound healing
2. a.) Describe numeric pain intensity scale. assessing changes in intensity scale?
time ___ met
the intensity of pain level and
pain using 0- evaluating ___ partially met
0 1 2 3 4 5 6 7 8 9 10 ___ not met
10 numeric interventions.
No moderate worst Reference:
pain intensity pain pain possible Medical Surgical Nursing
scale. pain by Smeltzer and Bare, 10th
Reference: edition, Vol 1, p245
Medical Surgical Nursing by Smeltzer and Bare,
10th edition, Vol 1, p228
 COR:
Pain is a subjective
experience and must
be described by the
client in order to
plan effective
treatment.
Reference:
Fundamentals of Nursing
by Kozier, 7th edition,
p1164
2b. State the
SOR: characteristics of
Assess and record pain and its Baseline data pain?
b.) State the characteristics: location, quality, provides information ___ met
characteristics of frequency and duration. for assessing ___ partially met
pain. changes in pain level ___ not met
and evaluation of
intervention.
Reference:
Nursing Process by
Christensen, 10th edition,
p296
3. Follow prescribed
SOR: pharmacological
Administer balance analgesics as Provides relief of regimen?
3. Follow prescribed to promote pain relief discomfort ___ met
prescribed Reference: ___ partially met
pharmacologic NANDA 9th Ed. P.49 ___ not met
al regimen.
COR:
Analgesics are more
effective if
administered early in
pain cycle.
Simultaneous use of
analgesics that work
on different portion
 of the nociceptive
system will provide
greater pain relief
with fewer side
effects.
Reference:
Medical Surgical Nursing
by Smeltzer and Bare, 10th
edition, Vol 1, p245
4. Verbalize level of
SOR: pain after the
4a.) Re-administer pain assessment Permits assessment administration of
4. Verbalize level scale. of effectiveness of analgesia?
of pain after analgesia and ___ met
the identify need for ___ partially met
administration further action if ___ not met
of analgesia. 0 1 2 3 4 5 6 7 8 9 10
ineffective.
No moderate worst Reference:
pain pain possible Medical Surgical Nursing
pain by Smeltzer and Bare, 10th
edition, Vol 1, p245
Reference:
Medical Surgical Nursing by Smeltzer and Bare, COR:
10th edition, Vol 1, p228 Pain is a subjective
experience and must
be described by the
client in order to
plan effective
treatment.
Reference:
Fundamentals of Nursing
by Kozier, 7th edition,
p1164

4b.) Document severity of patient’s pain SOR:

on chart. Assists in
demonstrating need
for additional
 analgesic or
alternative approach
to pain management.
Reference:
Medical Surgical Nursing
by Smeltzer and Bare, 10th
edition, Vol 1, p245

4c.) Obtain additional prescriptions as SOR:

needed. Inadequate pain
relief results in an
increase stress
response, suffering
and prolong
hospitalizations.
Reference:
Medical Surgical Nursing
by Smeltzer and Bare, 10th
edition, Vol 1, p245