Pain Nursing Care Plan
What would be nursing diagnosis for pain?
Nursing Care Plan 3 – Nursing Diagnosis: Acute Pain related to psychological distress as evidenced by patient verbalizing pain, moaning and crying, narrowed focus and altered passage of time, and pallor. Desired Outcome : Within 4 hours of nursing interventions, the patient will demonstrate a reduction in crying and pain verbalization.
|Assess to what extent cultural, environmental, intrapersonal, and intrapsychic factors may be contributing to pain.||These influences alter the patient’s expression of the pain experienced. This assessment can be used to evaluate each patient’s unique response.|
|Respond immediately to reports of pain.||If the patient is experiencing an altered passage of time due to pain, fear about delayed pain relief can exacerbate the pain experience. Prompt responses to reports of pain reduce anxiety and promote trust.|
|Promote periods of rest for the patient.||Fatigue can contribute to pain. A quiet, darkened room with minimal noise and interruptions can promote rest and reduce pain.|
|Use relaxation and breathing exercises and/or music therapy.||These techniques help produce a sense of tranquility for the patient. The goal is to reduce pain related to tension or stress,|
What are the 5 steps of nursing care plan?
Function – The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation. Assessment Assessment is the first step and involves critical thinking skills and data collection; subjective and objective.
Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight. Data may come from the patient directly or from primary caregivers who may or may not be direct relation family members. Friends can play a role in data collection.
Electronic health records may populate data and assist in assessment. Critical thinking skills are essential to assessment, thus the need for concept-based curriculum changes. Diagnosis The formulation of a nursing diagnosis by employing clinical judgment assists in the planning and implementation of patient care.
- The North American Nursing Diagnosis Association (NANDA) provides nurses with an up-to-date list of nursing diagnoses.
- A nursing diagnosis, according to NANDA, is defined as a clinical judgment about responses to actual or potential health problems on the part of the patient, family, or community.
- A nursing diagnosis encompasses Maslow’s Hierarchy of Needs and helps to prioritize and plan care based on patient-centered outcomes.
In 1943, Abraham Maslow developed a hierarchy based on basic fundamental needs innate to all individuals. Basic physiological needs/goals must be met before higher needs/goals can be achieved such as self-esteem and self-actualization. Physiological and safety needs provide the basis for the implementation of nursing care and nursing interventions.
- Basic Physiological Needs: Nutrition (water and food), elimination (Toileting), airway (suction)-breathing (oxygen)-circulation (pulse, cardiac monitor, blood pressure) (ABCs), sleep, sex, shelter, and exercise.
- Safety and Security: Injury prevention (side rails, call lights, hand hygiene, isolation, suicide precautions, fall precautions, car seats, helmets, seat belts), fostering a climate of trust and safety (therapeutic relationship), patient education (modifiable risk factors for stroke, heart disease).
- Love and Belonging: Foster supportive relationships, methods to avoid social isolation (bullying), employ active listening techniques, therapeutic communication, and sexual intimacy.
- Self-Esteem: Acceptance in the community, workforce, personal achievement, sense of control or empowerment, accepting one’s physical appearance or body habitus.
- Self-Actualization: Empowering environment, spiritual growth, ability to recognize the point of view of others, reaching one’s maximum potential.
Planning The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting.
- Care plans provide a course of direction for personalized care tailored to an individual’s unique needs.
- Overall condition and comorbid conditions play a role in the construction of a care plan.
- Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum.
Goals should be:
- Measurable or Meaningful
- Attainable or Action-Oriented
- Realistic or Results-Oriented
- Timely or Time-Oriented
Implementation Implementation is the step that involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care. This phase requires nursing interventions such as applying a cardiac monitor or oxygen, direct or indirect care, medication administration, standard treatment protocols, and EDP standards.
Evaluation This final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending upon overall patient condition.
The plan of care may be adapted based on new assessment data.
What are pain nurses responsibilities?
The licensed nurse is responsible and accountable to work toward effectively managing the patient’s pain through assessment, intervention and patient advocacy. and non-pharmacological interven- tions to control the patient’s identified pain.
What are the 6 Ps of nursing care?
The six Ps include: Pain, Position, Personal care needs, Proximity of belongings, Pumps and Promise.
What is a pain diagnosis?
Measuring pain can also be done by using The World Health Organization (WHO) “pain ladder” to describe its guideline for the use of drugs in the management of pain. The general principle is to start with first step drugs, and then to climb the ladder if pain is still present.
|Mild pain is self-limited. It goes away either with no therapy at all or with the use of nonprescription medication such as acetaminophen (Tylenol), aspirin, or other non-steroidal anti-inflammatory drugs (NSAIDs). Moderate pain is worse than mild pain and can interfere with function. You may be unable to ignore the pain and go on with all of the activities of daily living, but it goes away after a while and doesn’t come back after it has been treated. Moderate pain may need stronger medications than acetaminophen or nonprescription NSAIDs. Most NSAIDs, including ibuprofen (Motrin), have been found to be as effective at relieving pain as codeine. Severe pain is defined as pain that interferes with some or all of the activities of daily living. May cause bed confinement or chair rest because of the severity. Typically doesn’t go away, and treatment needs to be continuous for days, weeks, months, or years. For severe pain, strong opioids such as morphine, oxycodone, hydrocodone, hydromorphone, methadone, or fentanyl, as well as other medications (called adjuvant therapies) as needed for the particular kind of pain.|
image info This image is Copyright © My-MS.org and falls under Image License E defined under the Image License section of the Disclaimer page. Recognizing that the severity and intensity of pain is influenced by anxiety, stress and depression is important to pain treatment.
Understanding the influence of individual beliefs about pain, such as negative thinking that pain is overtaking life is important to managing pain. Recognizing individual strengths and coping strategies is important to managing pain. Finally, knowing who is there to help is important to pain management.
Physicians, however, do have a number of technologies they use to find the cause of pain. Primarily these include:
|•||Imaging, especially magnetic resonance imaging (MRI), provides physicians with pictures of the body’s structures and tissues. MRI uses magnetic fields and radio waves to differentiate between healthy and diseased tissue.|
|•||A neurological examination in which the physician tests movement, reflexes, sensation, balance, and coordination.|
|•||X-rays produce pictures of the body’s structures, such as bones and joints.|
To help with the pain and its reduction, exercise and physical therapy may help to decrease spasticity and soreness of muscles. Those with MS, however, may not always have the ability or endurance to do sufficient aerobic exercise. Regular stretching exercises do tend to help flexor spasms. Relaxation techniques such as progressive relaxation, meditation and deep breathing can contribute to the management of chronic pain. Other techniques which may help pain include massage, ultrasound, chiropractic treatments, hydrotherapy, acupuncture, transcutaneous nerve stimulation (TENS), moist heat and ice.
Why is pain a priority nursing diagnosis?
Determine factors that causes acute pain – 8. Investigate signs and symptoms related to pain. An accurate assessment of pain is crucial in providing an individualized plan of care. Bringing attention to associated signs and symptoms may help the nurse in evaluating the pain.
- In some instances, the existence of pain is disregarded by the patient.9.
- Determine the patient’s anticipation for pain relief.
- Some patients may be satisfied when pain is no longer intense; others will demand complete elimination of pain.
- This influences the perceptions of the effectiveness of the treatment modality and their eagerness to engage in further treatments.10.
Assess the patient’s willingness or ability to explore a range of techniques to control pain. Some patients may be hesitant to try the effectiveness of nonpharmacological methods and may be willing to try traditional pharmacological methods (i.e., the use of analgesics).
- A combination of both therapies may be more effective, and the nurse has the duty to inform the patient of the different methods to manage pain.11.
- Determine factors that alleviate pain.
- Ask clients to describe anything they have done to alleviate the pain.
- These may include, for example, meditation, deep breathing exercises, praying, etc.
Information on these alleviating activities can be integrated into planning for optimal pain management.
What are the 4 nursing diagnoses?
Types of Nursing Diagnoses – The four types of nursing diagnosis are Actual (Problem-Focused), Risk, Health Promotion, and Syndrome. Here are the four categories of nursing diagnoses: TYPES OF NURSING DIAGNOSES. The four types of nursing diagnosis are Actual (Problem-Focused), Risk, Health Promotion, and Syndrome.