Nursing Care Plan and Diagnosis for Chronic Pain

Nursing Care Plan and Diagnosis for Chronic Pain

This nursing care plan is designed for patients with chronic discomfort. According to Nanda,
chronic pain is the condition in which an individual experiences persistent or intermittent pain
that lasts for more than six months. This definition differs from that of acute pain, in which a
person experiences agony from one second to six months.

The patient may report typical symptoms of distress, but they have persisted for at least six
months. Due to the patient experiencing these symptoms for more than six months, the nurse
may observe social and familial relationship disruption, irritability, depression, a "beaten"
appearance, exhaustion, or somatic preoccupation.

There are numerous causes of chronic pain, including musculoskeletal disorders such as back
pain, treatment-related therapies such as chemotherapy, and pregnancy.

This nursing care plan for chronic back pain includes a nursing diagnosis, nursing interventions,
and nursing objectives.

What are intentions for geriatric care? How is a nursing care plan developed? Which nursing
care plan literature would you recommend to assist in the creation of a nursing care plan?

Care Plans are frequently developed in various formats. The format is not always crucial, and the
format of care plans may vary between nursing institutions and medical employment. Some
hospitals may display the information digitally or utilize pre-made templates. The most essential
aspect of the care plan is its content, as it will serve as the basis for your care.

Nursing Care Plan for Chronic Pain

Please observe the video below for a tutorial on how to construct a care plan in nursing school.
Otherwise, please continue down to view the finished care plan.

Scenario

A 56-year-old male presents with complaints of back discomfort. He states that he has
experienced consistent lower back pain for the past year. He explains that he decided to come in
to have it "checked out" because it is "taking a toll" on his ability to function. He reports that the
back pain has left him despondent and exhausted because he cannot perform the same tasks he
did a year ago. He also reports that his relationship with his wife and children has been affected.
You observe that the patient appears fatigued with dark circles under his eyes and is frequently
rubbing his back.
Nursing Diagnosis

Inflammation of the lumbar spine is the cause of the patient's one-year history of consistent
lower back pain, disruption of social and familial relationships, depression, fatigue, a "beaten
look," and rubbing of the painful area.

Subjective Data

He states that he has experienced consistent lower back pain for the past year. He explains that
he decided to come in to have it "checked out" because it is "taking a toll" on his ability to
function. He reports that the back pain has left him despondent and exhausted because he cannot
perform the same tasks he did a year ago. He also reports that his relationship with his wife and
children has been affected.

Objective Data

A 56-year-old male presents with complaints of back discomfort. You observe that the patient
appears fatigued with dark circles under his eyes and is frequently rubbing his back.

Nursing Outcomes

-At the next follow-up appointment, the patient will report an improvement in back pain and an
increase in daily activities.

-The patient will verbalize his expectations regarding the course of pain treatment and his
intended treatment outcomes and objectives.

-The patient will identify five noninvasive pain relief methods to aid in pain management.

-The patient will be instructed verbally on how to take the back pain medication prescribed for
him as needed.

Nursing Interventions

At the next follow-up appointment, the nurse will evaluate the patient's report of reduced back
pain and an increase in daily activities.

-The nurse will evaluate the patient's expectations regarding the duration of pain treatment and
his desired treatment outcomes.

-The nurse will educate the patient on five noninvasive pain relief techniques to aid in pain
management.

-The nurse will instruct the patient on how to take the back pain medication prescribed for him as
needed.
 SAMPLE Block format Soap Note
PATIENT INFORMATION

Name: Mr. W.S.

Age: 65-year-old

Sex: Male

Source: Patient

Allergies: None

Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime

PMH: Hypercholesterolemia

Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.

Surgical History: Appendectomy 47 years ago.

Family History: Father- died 81 does not report information

Mother-alive, 88 years old, Diabetes Mellitus, HTN

Daughter-alive, 34 years old, healthy

Social Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on
social celebrations. Retired, widow, he lives alone.

SUBJECTIVE:

Chief complain: “headaches” that started two weeks ago

Symptom analysis/HPI:

The patient is 65 years old male who complaining of episodes of headaches and on 3 different
occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100
respectively). Patient noticed the problem started two weeks ago and sometimes it is
accompanied by dizziness. He states that he has been under stress in his workplace for the last
month.

Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.

ROS:
CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss.
NEUROLOGIC: Headache and dizzeness as describe above. Denies changes in LOC. Denies
history of tremors or seizures.

HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in
vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or
drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain,
hoarseness, difficulty swallowing.

Respiratory: Patient denies shortness of breath, cough or hemoptysis.

Cardiovascular: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal

dyspnea.

Gastrointestinal: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or

diarrhea.

Genitourinary: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty

starting/stopping stream of urine or incontinence.

MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.

Skin: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.

Objective Data

CONSTITUTIONAL: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20,
PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 0/10.

General appearance: The patient is alert and oriented x 3. No acute distress noted.
NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation
intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.

HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no

tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye
movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema,
or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary
sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without
lesions,.Lids non-remarkable and appropriate for race.

Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling
or masses.
Cardiovascular: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2
sec.

Respiratory: No dyspnea or use of accessory muscles observed. No egophony, whispered

pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on
auscultation.

Gastrointestinal: No mass or hernia observed. Upon auscultation, bowel sounds present in all
four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no
rebound no distention or organomegaly noted on palpation

Musculoskeletal: No pain to palpation. Active and passive ROM within normal limits, no
stiffness.

Integumentary: intact, no lesions or rashes, no cyanosis or jaundice.

Assessment

Essential (Primary) Hypertension (ICD10 I10): Given the symptoms and high blood pressure
(156/92 mmhg), classified as stage 2. Once the organic cause of hypertension has been ruled out,
such as renal, adrenal or thyroid, this diagnosis is confirmed.

Differential diagnosis:

Ø Renal artery stenosis (ICD10 I70.1)

Ø Chronic kidney disease (ICD10 I12.9)

Ø Hyperthyroidism (ICD10 E05.90)

Plan

Diagnosis is based on the clinical evaluation through history, physical examination, and routine
laboratory tests to assess risk factors, reveal identifiable causes and detect target-organ damage,
including evidence of cardiovascular disease.

These basic laboratory tests are:

· CMP

· Complete blood count

· Lipid profile

· Thyroid-stimulating hormone
· Urinalysis

· Electrocardiogram

Ø Pharmacological treatment:

The treatment of choice in this case would be:

Thiazide-like diuretic and/or a CCB

· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily.

Ø Non-Pharmacologic treatment:

· Weight loss

· Healthy diet (DASH dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat
dairy products with reduced content of saturated and trans l fat

· Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but at least 1,000 mg/d
reduction in most adults

· Enhanced intake of dietary potassium

· Regular physical activity (Aerobic): 90–150 min/wk

· Tobacco cessation

· Measures to release stress and effective coping mechanisms.

Education

· Provide with nutrition/dietary information.

· Daily blood pressure monitoring at home twice a day for 7 days, keep a record, bring the record
on the next visit with her PCP

· Instruction about medication intake compliance.

· Education of possible complications such as stroke, heart attack, and other problems.

· Patient was educated on course of hypertension, as well as warning signs and symptoms, which
could indicate the need to attend the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes
understanding to all

Follow-ups/Referrals
· Evaluation with PCP in 1 weeks for managing blood pressure and to evaluate current
hypotensive therapy. Urgent Care visit prn.

· No referrals needed at this time.

References

Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017
(25th ed.). Print (The 5-Minute Consult Series).

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
ISBN 978-0-8261-3424-0

Patient Assessment and Care Plan

Instructions to student:

1) Bring one copy of this packet with you to clinical each week.

2) Your instructor will inform you of the number of packets and the dates each packet is due.
They may have you complete only portions of or all of the packet.

3) Read the rubric! Each packet is Pass/Fail. You must meet the requirements listed to receive a
Pass. Your instructor may ask you to resubmit packets that are incomplete or incorrect.

4) If your instructor asks you to submit the packet electronically, then please record your answers
in bold or in a colored or lower case font. This helps us identify your answers more quickly.

PATIENT ASSESSMENT FORM

STUDENT NAME: DATE:

GENDER ADMISSIO
CLIENT INITIALS: ROOM # DOB: AGE
: N DATE:
OCCUPATIO
MARITAL
CODE STATUS: ALLERGIES: N
STATUS:
(FORMER):
CHIEF
MEDICAL DX: COMPLAINT
:
PAST HISTORY
(SURGERY/PROCEDURE
S) WITH DATES
 RATIONAL
E (Why is
ORDERS this ordered
for this
client???)
Sodium is
restricted due
to edema in
the bilateral
2 g Sodium lower
diet with extremities
EXAMPLE: DIET
nectar thick and nectar
liquids only thick liquids
due to
dysphagia
from a past
stroke.
DIET
ACTIVITY
I/O
VS
BGM
FOLEY
NG
PEG/PEJ TUBE
WOUND CARE
RESPIRATORY
TREATMENT
TRACHEOSTOMY
SUCTIONING
CHEST TUBE
SPECIAL EQUIPMENT
LAB ORDERS
OTHER

ACTIVITY
OR
RATIONAL
REHAB SERVICES TREATMEN
E
T PLAN &
SCHEDULE
PHYSICAL THERAPY
SPEECH THERAPY
OCCUPATIONAL
THERAPY

....../ 5 pts

IVs

IV FLUID AND RATE: SITE LOCATION AND CONDITION:

LAST DRESSING CHANGE: LAST TUBING CHANGE:
GAUGE: REASON FOR IV ACCESS:

DIAGNOSTIC REASON FOR TESTING AND

DATE RESULTS
TESTS: IMPLICATIONS FOR NURSING CARE

IMPLICATIONS FOR NURSING CARE

NORMS
LAB (WHAT S&S I SHOULD BE AWARE OF
DATE RESULTS REFERENCE
TEST AND WHAT YOU CAN DO TO HELP
RANGES
IMPROVE AN ABNORMAL RESULT?)
GROWTH and DEVELOPMENT: (see pages 378-379 Taylor, Lillis and White) or (Erikson’s
Stages of Development)

TASKS OF THIS
STAGE:

CLIENT’S DEVELOPMENTAL STAGE ACCORDING TO

HAVIGHUSRT

ASSESSMENT OF CLIENT’S SUCESSFUL ACHIEVEMENT OF

TASKS

...../ 5 pts

MEDICATIONS

If your client has more than 12 medications, select the 12 medications that are most important,
most frequently given or those that pertain to the client’s most significant medical problems. See
the example below.

Brand Name and Generic Name Normal Dosage Ranges Contraindications

Coreg (carvedilol)
3.125 mg – 50 mg BID Asthma, heart block

Pharmacotherapeutic Class Dosage, Route & Frequency Adverse Reactions

β-adrenergic blocker
Why this Patient Receives this
Med
He has a history of hypertension
but has been taking Coreg for 2
years to control his hypertension
Bradycardia, CHF,
6.25 mg p.o. BID thrombocytopenia,
hyperglycemia, bronchospasm
Effects of the Med on the Nursing Considerations and
Client Teaching
Do not discontinue abruptly or
BP’s for past 3 days have before surgery
been 128/78, 132/72, 138/80
Caution with Upper airway
dysfunction
How is this medication Rise slowly to minimize
impacting your client??B/P orthostatic hypotension, check
readings, lab results, pain B/P and heart rate prior to
management, etc…….. administration
 Take before meals

#1 Brand Name and Generic

Normal Dosage Ranges Contraindications
Name

Pharmacotherapeutic Class Dosage, Route & Frequency Adverse Reactions

Why this Patient Receives this Effects of the Med on the Nursing Considerations and
Med Client Teaching

#2 Brand Name and Generic

Normal Dosage Ranges Contraindications
Name

Dosage, Route and

#3 Pharmacotherapeutic Class Adverse Reactions
Frequency

Why this Patient Receives this Effects of the Med on the Nursing Considerations and
Med Client Teaching

#4 Brand Name and Generic

Normal Dosage Ranges Contraindications
Name

Pharmacotherapeutic Class Dosage, Route and Adverse Reactions

 Frequency

Why this Patient Receives this Effects of the Med on the Nursing Considerations and
Med Client Teaching

#5 Brand Name and Generic

Normal Dosage Ranges Contraindications
Name

Dosage, Route and

Pharmacotherapeutic Class Adverse Reactions
Frequency

Why this Patient Receives this Effects of the Med on the Nursing Considerations and
Med Client Teaching

# 6 Brand Name and Generic

Normal Dosage Ranges Contraindications
Name

Dosage, Route and

Pharmacotherapeutic Class Adverse Reactions
Frequency

Why this Patient Receives this Effects of the Med on the Nursing Considerations and
Med Client Teaching
#7 Brand Name and Generic
Normal Dosage Ranges Contraindications
Name

Dosage, Route and

Pharmacotherapeutic Class Adverse Reactions
Frequency

Why this Patient Receives this Effects of the Med on the Nursing Considerations and
Med Client Teaching

#8 Brand Name and Generic

Normal Dosage Ranges Contraindications
Name

Dosage, Route and

Pharmacotherapeutic Class Adverse Reactions
Frequency

Why this Patient Receives this Effects of the Med on the Nursing Considerations and
Med Client Teaching

#9 Brand Name and Generic

Normal Dosage Ranges Contraindications
Name

Dosage, Route and

Pharmacotherapeutic Class Adverse Reactions
Frequency
Why this Patient Receives this Effects of the Med on the Nursing Considerations and
Med Client Teaching

#10 Brand Name and Generic

Normal Dosage Ranges Contraindications
Name

Dosage, Route and

Pharmacotherapeutic Class Adverse Reactions
Frequency

Why this Patient Receives this Effects of the Med on the Nursing Considerations and
Med Client Teaching

#11 Brand Name and Generic

Normal Dosage Ranges Contraindications
Name

Dosage, Route and

Pharmacotherapeutic Class Adverse Reactions
Frequency

Why this Patient Receives this Effects of the Med on the Nursing Considerations and
Med Client Teaching
#12 Brand Name and Generic
Normal Dosage Ranges Contraindications
Name

Dosage, Route and

Pharmacotherapeutic Class Adverse Reactions
Frequency

Why this Patient Receives this Effects of the Med on the Nursing Considerations and
Med Client Teaching

...../ 20 pts

NURSES NOTES FOR CLINICAL

For this clinical, we are having you write out your assessment findings in the form of a narrative
nurse’s note. We have provided some samples of assessments. We have also provided a
worksheet that you may use to take into a patient’s room to take notes during your assessment.
Record your vital signs and type your physical assessment findings. This form will expand to fit
your typing. A sample of charting for a long

resident follows below.

TEMP: APICAL HR: RESP: BP: HT: WT:

(TYPE HERE)

DATE / TIME

Sample Narrative Note --- Head to Toe format

Temp: 98.6 Apical HR: 72 Resp: 16 BP 128/62 Ht: 5’10” Wt: 145

Resident in semi-fowlers position in bed. Pressure reduction mattress in place.

Alert and oriented x 3. Appropriate mood and affect. Well groomed. Recent and
remote memory intact. Facial symmetry noted. Pupils are equal, reactive to light
and accommodation. Oral mucosa moist, pink. Frequent oral care rendered with
sponge toothette and toothbrush. Dentition intact. Hearing intact. Oropharynx clear
without erythema or exudate. No chewing or swallowing difficulties. 75% of
general diet taken at breakfast. Skin pink, warm, dry, free of lesions with elastic
turgor. Hair and nails unremarkable. Carotid and radial pulses present and equal.
Motor and sensory functions grossly intact. No weakness or paralysis. Upper
extremities equal strength bilaterally, full ROM w/ capillary refill < 3 sec. Fine
resting tremor in the left hand” No involuntary movement or abnormal posture.
12/22/2010
Lungs clear bilaterally to auscultation. Tracheostomy dressing clean, dry, and
1400
intact. Connected to ventilator with settings: TV-550, Fio2-40%, Rate 10, and
PEEP-5cm. Sao2-92%. Suctioned for moderate amount of white, thin secretion.
Apical pulse regular (rate) and rhythm. Double lumen picc line note to left
antecubital space. Tegaderm dressing is clean, dry, and intact. Last dressing change
on 11/28/16. Chlorhexadine caps intact to all lumens. Bowel sounds active x 4.
Abdomen soft, non-distended, non-tender. Last bowel movement this morning,
passed a large, soft- formed brown stool and a moderate amount of clear yellow
urine. Bilateral lower extremities, no tenderness, swelling or joint deformities
noted. Denies numbness or tingling to extremities. Toe nails thick and yellowed w/
capillary refill < 3 sec. No peripheral edema noted, pedal pulses palpable and equal
bilaterally.

PHYSICAL ASSESSMENT WORKSHEET (Use this sheet for jotting down

your assessment findings.)

ROUTINE FINDINGS PATIENT VARIATIONS/ABNORMALS

COGNITION/NEUROLOGICAL (SAMPLE)
(SAMPLE) “Fine resting tremor of left hand
Alert and oriented x3, recent and remote
memory intact. Denies any numbness or
tingling to extremities”
SKIN

Wound measurements and complete

description if available at the very least
SENSORY
Document dressing including the type of
dressing and description of condition!
BREASTS - DEFERRED.
(Include ventilator settings as indicated in
narrative note)
RESPIRATORY –

Include any vascular access device, IV lines,

AV fistulas, perma -cath lines, etc.
CARDIOVASCULAR

Include any enteral feedings here and route

ABDOMEN –

.
BOWEL CONTINENCE? LAST BM? BOWEL
PLAN?

MUSCULOSKELETAL -

URINARY CONTINENCE? TOILETING

PLAN?
GENITOURINARY -

DEFERRED.
PELVIC -

RECTAL - DEFERRED.

....../ 10 pts

NURSING CARE PLAN Begin your NCP by listing ALL your clients individual problems (at
least 10) and then identify an appropriate nursing diagnosis that you can think of that would
apply to your client. Determine which 3 problems/nursing diagnoses are of greatest priority and
then add a #1, #2, and #3 to indicate which of the two have highest priority. Risks would not be
priority 1, 2, or 3!!!!!

Expectation is to have at least 10 nursing diagnosis listed!

 An appropriate As evidenced by part of the
Nursing Diagnosis statement (This is
Related to part of the
stem individual to your client)
List the Client statement (This is
#
problem individual to your
(REFER TO YOUR REMEMEBR THIS IS
client)
NURSING NOT USED IN A “Risk
DIAGNOSIS LIST) For” diagnosis
SAMPLE: Reports “as evidenced by” verbal
“related to” fractured
1 severe pain in the “Acute Pain” report of pain rated at an 8
right hip
right hip. on a scale of 0 –to 10.
NONE it is a “Risk for”
SAMPLE: “Risk for Impaired “related to “
2 diagnosis so there is no
Complete bed rest skin integrity” immobility
evidence statement

From the list above your faculty member will give you direction regarding how many and which
diagnoses they want you to develop for either a Nursing Care Plan and/or a Concept Map.

SAMPLE NCP

NANDA DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED

BY STATEMENT: Acute Pain related to right hip fracture as evidenced by a verbal
report of pain rated 8 on a scale of 0 -10.

OUTCOME
ASSESSMEN STATEMEN SCIENTIFIC EVALUATIO
INTERVENTIONS
T T RATIONALE N OF
OUTCOME
(Individualized,
(Data that (Patient (Supporting statement
specific, frequency)
directly centered, from text or other (Met, partially
pertains to the
realistic, source, cite source) met, unmet,
Minimum of 4-5
specific,
above nursing unknown by
interventions per plan
diagnosis) measurable, target time)
target time)
SUBJECTIVE SHORT 1. Educate the client on 1. “There are many ways Short Term
DATA: “My TERM: Client the importance of pain to manage pain. In Goal: Met; pain
right hip hurts will report relief to enhance her addition to was rated at a 2
me so much pain level rehabilitation efforts pharmacologic and non- on a scale of 0
every time I rated at a 3 or and include education pharmacologic to 10 after
move. I am so lower 30 on various types of measures, simple administration
afraid to start minutes after methods to relieve pain. nursing interventions can of Vicodin.
physical pain alter patients’ pain
therapy” medication experience and speed
taken their recovery.” Taylor,
Lillis and White pg.
1168.
2. Encourage client to
express any questions or
concerns she may have
regarding pain 2. “Common fears
management methods to include a loss of control
alleviate anxiety and and embarrassment by
fears. being unable to deal with Long Term
pain maturely… The Goal. In
patient may view the progress
need of for medication
as a sign of weakness or
may fear addiction or
loss of effectiveness at a
later date.” Taylor, Lillis
3. Educate the client on and White pg. 1169.
her responsibility to
honestly report pain
when it occurs as well
as reporting if the
current pain
management is effective 3. “As a patient
or ineffective for advocate, ensure that a
providing her pain relief strong emphasis on the
need for aggressive,
individualized strategies
that can minimize or
4. Provide for eliminate acute pain and
alternative/complement improve patient
ary measures of pain outcomes. Preventing
relief, such as, reduce pain is easier then
lighting and noise, treating it once after it
soothing music, pet occurs.” Taylor, Lillis
therapy, massage, and and White pg. 1178.
hot/cold packs
according to client
 preferences.

4.
Alternative/complement
ary measures will
provide an added benefit
of distraction from pain
experience and augment
analgesic effect.
Cold/hot therapy can
provide constriction and
or dilation which will
reduce pain
inflammation in each
specific circumstance
Daniels. Pg 378
OBJECTIVE
DATA:

Alert and
oriented 70
year old
widowed
female. Lives
in an
apartment
LONG
independently.
TERM: Client
2 daughter live
will report
nearby and
pain level of 2
visit often.
or less using
ibuprofen
History of a
with
fall while out
alternative
shopping 1 ½
pain control
weeks ago.
methods by
Right hip
discharge.
surgically
repaired 7 days
ago. Surgical
dressing to
right hip is
clean, dry and
intact.
Circulation,
motion and
sensation intact
to right lower
extremity.

Afebrile; BP
124/80; R-18
AP 84 and
regular. 5 foot
7 inches
weighs 142
pounds. No
hearing
deficits; wears
eye glasses

Medical
history positive
for
osteoarthritis
and
osteoporosis

Non weight
bearing to right
leg and to use
a walker for
ambulation

To start
physical
therapy for gait
and strength
training BID
times 7 days
and
occupational
therapy to
develop upper
body strength
once daily
times 7 days

Reports pain
level is at 8 on
a scale of 0 to
10.
Has Vicodin
5mg/325 mg
po 2 tabs every
4 hours prn for
severe pain

Ibuprofen 400
mg every 6
hours prn for
moderate pain.

Short term outcome: An outcome that can be accomplished by the end of the student clinical day.

Interventions: Each nursing intervention must come from a reliable nursing reference or source.
Please note: do not use nursing care planning book exclusively. Not more than one
intervention can come from a source outside your textbooks.

Rationales: Cite a reliable source for each intervention (name of text, author, page number,
internet site and date retrieved (reliable sites: .gov or .edu. or .org)

NANDA DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED

BY STATEMENT:

SCIENTIFIC
RATIONALE
OUTCOME EVALUATION
ASSESSMENT
STATEMENT OF OUTCOME
INTERVENTIONS (Supporting
(Data that directly statement from
(Patient centered, (Met, partially
pertains to the (Individualized, text or other
realistic, specific, met, unmet,
above nursing specific, frequency) source, cite
measurable, unknown by target
diagnosis) source)
target time) time)

SUBJECTIVE
SHORT TERM:
DATA:
OBJECTIVE
LONG TERM:
DATA:
Short term outcome: An outcome that can be accomplished by the end of the student clinical day.

Interventions: Each nursing intervention must come from a reliable nursing reference or source.
Please note: do not use nursing care planning book exclusively. Not more than one
intervention can come from a source outside your textbooks.

Rationales: Cite a reliable source for each intervention (name of text, author, page number,
internet site and date retrieved (reliable sites: .gov or .edu. or .org)

...../30

NANDA DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED

BY STATEMENT:

SCIENTIFIC
RATIONALE
OUTCOME EVALUATION
ASSESSMENT
STATEMENT OF OUTCOME
INTERVENTIONS (Supporting
(Data that directly statement from
(Patient centered, (Met, partially
pertains to the (Individualized, text or other
realistic, specific, met, unmet,
above nursing specific, frequency) source, cite
measurable, unknown by target
diagnosis) source)
target time) time)

SUBJECTIVE
SHORT TERM:
DATA:
OBJECTIVE
LONG TERM:
DATA:

Short term outcome: An outcome that can be accomplished by the end of the student clinical day.

Interventions: Each nursing intervention must come from a reliable nursing reference or source. .
Please note: do not use nursing care planning book exclusively. Not more than one
intervention can come from a source outside your textbooks.
Rationales: Cite a reliable source for each intervention (name of text, author, page number,
internet site and date retrieved (reliable sites: .gov or .edu. or .org)

..../30

NANDA DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED

BY STATEMENT:

SCIENTIFIC
RATIONALE
OUTCOME EVALUATION
ASSESSMENT
STATEMENT OF OUTCOME
INTERVENTIONS (Supporting
(Data that directly statement from
(Patient centered, (Met, partially
pertains to the (Individualized, text or other
realistic, specific, met, unmet,
above nursing specific, frequency) source, cite
measurable, unknown by target
diagnosis) source)
target time) time)

SUBJECTIVE
SHORT TERM:
DATA:
OBJECTIVE
LONG TERM:
DATA:

Short term outcome: An outcome that can be accomplished by the end of the student clinical day.

Interventions: Each nursing intervention must come from a reliable nursing reference or source. .
Please note: do not use nursing care planning book exclusively. Not more than one
intervention can come from a source outside your textbooks.

Rationales: Cite a reliable source for each intervention (name of text, author, page number,
internet site and date retrieved (reliable sites: .gov or .edu. or .org)

................/30

Key Problem: Impaired urinary elimination

Data:
Intake=3800 Output=3200

Polyuria

3+ glucose in urine

AEB: Polydipsia and polyuria

Outcomes:

Pt. will have urine output of 1000 – 2000 ml/24 hours.

Interventions:

Monitor I & O q shift.

Monitor BGM a.c. and h.s.

Monitor kidney function tests

Administer antihyperglycemics as ordered.

Key Problem: Knowledge deficit

Data: Pt verbalizes confusion about diagnosis, new meds, diet, exercise routine

AEB: Verbal statements and questions.

Outcomes:

Pt will verbalize understanding of ADA diet and administer insulin using appropriate technique
by discharge.

Interventions:

Assess level of knowledge regarding diabetes/ treatment and client’s preferred learning style.

Provide information q shift according to teaching plan recorded in EMR and document pt’s
response.

Reassess level of knowledge daily.

Provide written information.

Provide educational resources available in the community.

Medical Problems (Pathophysiology)/Surgical Procedures:

Newly diagnosed diabetic

Key Assessments:

S/S of hyper and hypoglycemia, good intake, I/O, glucose level, vitals

Tests: FBS, hemoglobin A1C

“I don’t know how this fits”

Recent widow

Kids live out of state

? support system

Key Problem: Acute anxiety

Data: Restless, verbally states she is anxious.

AEB: Pt states “I don’t know what I will do with diabetes, this is too much.”

Outcomes: Pt. will verbalize under-standing of resources available by discharge.

Interventions:

Provide pt. with an opportunity each shift to verbalize anxiety by asking open ended questions.

Demonstrate progressive relaxation exercises and have pt. return demonstrate.

Provide pt. with a list of community resources for newly diagnosed diabetics.

Identify client’s perception of anxiety

Utilize empathy.

Past Medical History: Hypertension x 20 years; appendectomy at age 9.

Risk Factors: Mother had Type 2 diabetes; hypertension; Native American descent; sedentary
lifestyle; 290 pounds, age 52

Key Problem:
Imbalanced nutrition, more than

Data:

BMI: 35.0–39.9; Ht: 5”9; Wt: 290 lbs

AEB: Anthropometric measurements.

Outcomes: Client will verbalize a realistic weight loss goal and three strategies to reach it prior
to discharge.

Interventions:

Assess client’s knowledge of nutrition and its relationship to diabetes.

Arrange for dietary consultation.

Reinforce teaching by dietician.

Encourage physical activity as a weight loss strategy.

Provide pt with community resources that can assist her with weight loss goal.

“I DON’T KNOW HOW THIS FITS”

PAST MEDICAL HISTORY

RISK FACTORS

MEDICAL PROBLEMS (PATHOPHYSIOLOGY)/SURGICAL PROCEDURES:

KEY ASSESSMENTS:

Key Assessments:
Tests:

KEY PROBLEM:

DATA:

AEB:

OUTCOMES:

INTERVENTIONS:

KEY PROBLEM:

DATA:

AEB:

OUTCOMES:

INTERVENTIONS:

RUBRIC for Grading Packets

/60pts

KEY PROBLEM:

DATA:

AEB:

OUTCOMES:

INTERVENTIONS:

KEY PROBLEM:

DATA:

AEB:

OUTCOMES:

INTERVENTIONS:
Student Name: Clinical Date: Site:

Comments,
Kudos,
Satisfactory Or
Section Grading Criteria
Unsatisfactory Things to
Improve for
Next Time
10 points Page 1 fully and correctly
completed 5 pts _/5___
Patient Demographics,
Page 2 fully and correctly _/5___
Diagnoses, Surgeries, completed 5 pts
Orders, Rehab, IV,
Imaging and Lab
/2
Medication Trade Name 2 pts
/2
Medication Generic Name 2 pts
/2
Pharmacological Classification 2 pts
/2
Normal Dosage Range 2 pts
20 points
/2
Dose ordered 2 pts
Medications
/2
Route and Frequency 2 pts
/2
Contraindications 2 pts
/2
Adverse Effects/Reactions 2 pts
/2
Nursing Considerations & Teaching
2 pts
/2
(Legible or typed) 2 pts
_/20__
Narrative note is in Head to Toe
10 points order

Narrative Notes Head-to-toe assessment documented

Abnormal results noted 10 pts
___/10_
Head-to-Toe Nursing Care Plan and Diagnosis
Assessment for Chronic Pain
 Correct Medical Diagnosis 15 pts

Pathophysiology 15 pts
60 points (either a
Concept Map or a ____/60
Key Assessments 15 pts
Patient Care Plan)
At least 3 problems identified 15 pts
Concept Map
OR
Nursing Care Plan and Diagnosis
for Chronic Pain
3 nursing diagnoses Related to” “As
evidenced by” 18 pts
60 points (either a
2 Outcomes specific, measurable,
Concept Map or a
timed 8 pts
Patient Care Plan)
4-5 Interventions are logical,
Patient Care Plan
appropriate 15 pts

4-5 Scientific Rationales supporting

each intervention 15 pts 2
Evaluations 4 pts

Nursing Care Plan for Pain with Diagnosis and Nursing

Intervention
Nursing Care Plan for Pain with Diagnosis and Nursing Intervention

Pain classifications Acute pain:

Mild to severe pain lasting less than six months; associated with a sympathetic nervous system
response; resulting in increased pulse rate and volume, increased respiratory rate and depth,
increased blood pressure, and increased glucose levels; decreased urine production and
peristalsis.

The protective function of acute pain is to alert the patient of injury or infection. The onset of
sudden severe pain prompts the patient to seek solace. The physiological manifestations of acute
pain result from the body's tension response to the pain. Acute pain may be exacerbated by the
patient's cultural context, emotions, and psychological or spiritual distress. The assessment of
pain can be challenging, particularly in elderly patients with cognitive impairment and sensory
perception deficits.
Chronic ache:

Mild to severe pain lasting longer than six months; associated with the parasympathetic nervous
system; the patient may not exhibit acute pain-related signs and symptoms. may result in
despondency and diminished function

Terms for suffering

Pain threshold is the minimum quantity of stimulus required to produce a painful sensation.
The maximum quantity of pain that a patient is willing or able to tolerate.
Pain felt in a location other than the origin of a tissue injury
Pain that cannot be relieved by conventional treatments is untreatable.
Neuropathic pain: agony caused by a neurological disorder and unrelated to tissue damage
Phantom pain: pain felt in an absent body part Radiating pain: pain felt at the source that spreads
to other locations.

[caption id="attachment_15455" align="alignright" width="345"] Nursing Care Plan and

Nursing Intervention[/caption]

Plan of nursing care for pain that includes intervention and pain

Affiliated with suffering

medical concerns
Diagnostic techniques and medical care
emotionally and mentally traumatic
Aspirational Cultural distress.

Desired Results

On a scale from 0 to 10, the patient reports adequate

pain control with a score of less than 3 to 4.
The patient is capable of utilizing both
pharmacologic and nonpharmacologic pain relief
strategies.
Patient feels more at ease, as demonstrated by a
regulated pulse, blood pressure, respiration, and calm
muscle tension and posture.

May be exemplified by.

Protective behavior, body protection, egocentric,

narrowed focus
Relief or diversion methods
Pain masking the face
Consideration of muscular tone
Nursing care plan for pain with intervention and rationale
Nursing intervention
Assessment of pain characteristics. ex.
Quality, severity, location, onset, duration,
precipitating and relieving factors
Screening for signs and symptoms related pain can help the nurse assess pain.
to pain.
For scientific findings and symptoms
associated with chronic pain, such as
fatigue, decreased appetite, weight loss,
change in posture, disruption of sleep
patterns, anxiety, agitation, or depression.
Evaluate the patient’s response to pain and
pain management strategies.
Assess patient’s expectations for pain
relief.
Anticipate the need for pain relief.
Eliminate additional stressors or
discomfort whenever possible.
Provide rest periods to promote comfort,
sleep, and relaxation.
Determine the appropriate method for pain Unless contraindicated, all patients with acute pain
relief.
Rationale
Assessment of the pain experience is the first step in
planning pain management strategies. The patient is
the most reliable source of information about his or
her pain.
Some people deny the sensation of pain even though
it is present. Paying attention to signs associated with
A patient with acute pain may have elevated blood
pressure, heart rate, temperature, be agitated, and
have difficulty concentrating.
Patients with chronic pain may not exhibit the
physical changes and behaviors associated with acute
pain. Pulse and blood pressure are usually within the
normal range.
It is important to assist the patient in presenting the
effect of pain-relieving measures as factually as
possible. Discrepancies between the patient’s
behavior or demeanor and what he or she says about
pain relief.
Some patients are satisfied with pain relief, while
others expect complete elimination of pain, which
affects their perception of the effectiveness of the
treatment method and their willingness to participate
in further treatment.
The most effective way to address pain is to prevent
it. Early intervention can reduce the total amount of
analgesics needed.
Patients may experience exaggeration of pain or
diminished ability to tolerate painful stimuli if they
experience additional stress from environmental,
intrapersonal, or intrapsychic factors.
The patient’s perception of pain may be exaggerated
by fatigue. In a cycle, pain can lead to fatigue, which
in turn can lead to exaggerated pain and fatigue. A
quiet environment, a darkened room, and a phone
turned off are measures that facilitate recovery.
should receive a nonopioid analgesic around the
 clock.
Heat reduces pain by improving blood flow to the
area and reducing pain reflexes. Cold reduces pain,
Hot or cold compress inflammation, and spastic massage by decreasing the
release of pain-inducing chemicals and slowing the
transmission of pain impulses.
Increases endorphin levels and decreases tissue
Massage of the painful area edema. This intervention may require another person
to perform the massage.
Administer analgesics as ordered by a Analgesics are absorbed and metabolized differently
physician, evaluate their effectiveness, and by patients, so their effectiveness must be assessed
observe signs and symptoms of side by the patient individually. Analgesics usually have
effects. side effects that range from mild to life-threatening.
Notify the physician if interventions are
Patients who request pain medications at shorter
unsuccessful or if current symptoms
intervals than prescribed may actually require a
represent a marked change from the
higher dose or stronger analgesics.
patient’s previous pain experience.
Knowing what to expect can help patients develop
Anticipatory education about the causes of
effective coping strategies for pain management.
pain and appropriate measures for
Patients need to learn the importance of reporting
prevention and relief.
pain early to achieve more effective pain relief.
The patient should learn how to effectively
discontinue the medication dose in relation Patients must learn to use pain relief strategies to
to potentially unpleasant activities and minimize the pain experience.
avoidance of pain spikes.
Assist the patient and family in identifying Changes in work routine, household responsibilities,
lifestyle changes that can contribute to and home environment may be necessary to promote
effective pain management. Guide the more effective pain management. Ongoing support
patient to plan activities during the times and guidance for the patient and family will increase
when pain is at its greatest relief. the success of these strategies.

How to Write a Nursing Care Plan

How to Write a Nursing Care Plan

Nursing Care Plan Components

A nursing care plan has several key components including,

 Nursing diagnosis
  Expected outcome
 Nursing interventions and rationales
 Evaluation

Each of the five main components is essential to the overall nursing process and care plan. A
properly written care plan must include these sections otherwise, it won’t make sense!

 Nursing diagnosis - A clinical judgment that helps nurses determine the plan of care for
their patients
 Expected outcome - The measurable action for a patient to be achieved in a specific time
frame.
 Nursing interventions and rationales - Actions to be taken to achieve expected
outcomes and reasoning behind them.
 Evaluation - Determines the effectiveness of the nursing interventions and determines if
expected outcomes are met within the time set.

How to Write a Nursing Care Plan

Determine the patient's most significant issues prior to composing the nursing care plan.
Consider both medical and psychosocial difficulties. At times, a patient's psychosocial concerns
may be more pressing or even hold up his or her discharge than the patient's actual medical
problems.

After compiling a list of the patient's issues and the corresponding nursing diagnosis, you must
determine which are the most significant. In general, this is done by contemplating the ABCs
(Airway, Breathing, Circulation). However, these won't ALWAYS be the most significant or
even pertinent for your patient.

Step 1: Assessment

The first step in writing an organized care plan includes gathering subjective and objective data.
Subjective data is what the patient tells us their symptoms are, including feelings, perceptions,
and concerns. Objective data is observable and measurable.

This information can come from,

 Verbal statements from the patient and family

 Vital signs
o Blood pressure
o Heart rate
o Respirations
o Temperature
o Oxygen Saturation
 Physical complaints
o Pain
o Headache
 o Nausea
o Vomiting
 Body conditions
o Head-to-toe assessment findings
 Medical history
 Height and weight
 Intake and output
 Patient feelings, concerns, perceptions
 Laboratory data
 Diagnostic testing
o Echocardiogram
o X-Ray
o EKG

Step 2: Diagnosis

Using the information and data gathered in Step 1, the nursing diagnosis that best suits the
patient, his or her hospitalization goals and objectives is selected.

North American Nursing Diagnosis Association (NANDA) defines nursing diagnosis as "a
clinical judgment about the human response to health conditions/life processes, or a vulnerability
for that response, by an individual, family, group, or community."

The nursing diagnosis is founded on Maslow's Hierarchy of Needs and assists with treatment
prioritization. The next stage involves determining the goals for resolving the patient's problems
through nursing interventions based on the nursing diagnosis selected.

There are 4 types of nursing diagnoses.

1. Problem-focused - Patient problem present during a nursing assessment is known as a

problem-focused diagnosis
2. Risk - Risk factors require intervention from the nurse and healthcare team prior to a real
problem developing
3. Health promotion - Improve the overall well-being of an individual, family, or
community
4. Syndrome - A cluster of nursing diagnoses that occur in a pattern or can all be addressed
through the same or similar nursing interventions

After determining which type of the four diagnoses you will use, start building out the nursing
diagnosis statement.

The three main components of a nursing diagnosis are:

1. Problem and its definition - Patient’s current health problem and the nursing
interventions needed to care for the patient.
 2. Etiology or risk factors - Possible reasons for the problem or the conditions in which it
developed
3. Defining characteristics or risk factors - Signs and symptoms that allow for applying a
specific diagnostic label/used in the place of defining characteristics for risk nursing
diagnosis

Examples:

PROBLEM-FOCUSED DIAGNOSIS

Problem-Focused Diagnosis related to ______________________ (Related Factors) as

evidenced by _________________________ (Defining Characteristics).

RISK DIAGNOSIS

The correct statement for a NANDA-I nursing diagnosis would be: Risk for _____________ as
evidenced by __________________________ (Risk Factors).

Step 3: Outcomes and Planning

After determining the nursing diagnosis, it is time to create a SMART goal based on evidence-
based practices. SMART is an acronym that stands for,

 Specific
 Measurable
 Achievable
 Relevant
 Time-Bound

It is essential to take into account the patient's medical diagnosis, overall condition, and all
collected data. A physician or other advanced healthcare professional makes a medical diagnosis.
It is essential to remember that a medical diagnosis does not change if the patient's condition
improves, and it remains a permanent part of the patient's medical history.

Examples of medical diagnosis include,

 Chronic Lung Disease (CLD)

 Alzheimer’s Disease
 Endocarditis
 Plagiocephaly
 Congenital Torticollis
 Chronic Kidney Disease (CKD)

During this period, you will also consider the patient's goals and short- and long-term outcomes.
These objectives must be achievable and desired by the patient. For instance, if a goal is for the
patient to seek counseling for alcoholism during hospitalization, but the patient is currently
detoxifying and experiencing mental distress, this goal may not be achievable.

Step 4: Implementation

Now that the objectives have been established, you must take the necessary steps to assist the
patient in achieving them. While some actions will produce immediate results (e.g.,
administering a suppository to a patient with constipation to induce a digestive movement),
others may not be observed until later in the hospitalization.

The implementation phase means performing the nursing interventions outlined in the care plan.
Interventions are classified into seven categories:

 Family
 Behavioral
 Physiological
 Complex physiological
 Community
 Safety
 Health system interventions

Some interventions will be patient or diagnosis-specific, but there are several that are completed
each shift for every patient:

 Pain assessment
 Position changes
 Fall prevention
 Providing cluster care
 Infection control

Step 5: Evaluation

The fifth and final step of the nursing care plan is the evaluation phase. This is when you
evaluate if the desired outcome has been met during the shift. There are three possible outcomes,

 Met
 Ongoing
 Not Met

On the basis of the evaluation, it can be determined whether the objectives and interventions
need to be modified. Ideally, all nursing care plans, including objectives, should be met prior to
discharge. This is not always true, particularly when a patient is being discharged to hospice,
home care, or a long-term care facility. Initially, you will discover that the majority of care plans
will have ongoing objectives that may be met within a few days or weeks. It depends on the
patient's condition and the desired outcomes.
Consider selecting objectives that the patient is capable of achieving. This will not only help the
patient feel as though they are making progress, but it will also relieve the nurse by allowing
them to monitor the patient's overall progress.

Nursing Care Plan Fundamentals

Nursing care plans contain information about a patient’s diagnosis, goals of treatment, specific
nursing interventions, and an evaluation plan. The nursing plan is constantly updated with
changes and new subjective and objective data.

Key aspects of the care plan include,

 Assessment
 Diagnosis
 Outcome and Planning
 Implementation
 Evaluation

Through subjective and objective data, constantly assessing your patient’s physical and mental
well-being, and the goals of the patient/family/healthcare team, a nursing care plan can be a
helpful and powerful tool.

Evidence-Based Practice in Nursing

Examine the importance of incorporating current research evidence into clinical decision-

making and discuss the steps involved in implementing evidence-based practice in nursing care.

Evidence-based practice (EBP) in nursing is a systematic approach that integrates the best

available research evidence, clinical expertise, and patient preferences to guide clinical decision-

making and improve patient outcomes. It involves critically appraising and applying research

findings to inform nursing practice, ensuring that interventions and care are based on the most

up-to-date and reliable evidence. Here is a detailed explanation of evidence-based practice in

nursing:
1. Importance of Evidence-Based Practice:

 Enhancing Patient Outcomes: By incorporating current research evidence into

clinical decision-making, nurses can provide care that is more effective, safe, and

aligned with best practices, leading to improved patient outcomes.

 Ensuring Quality and Safety: Evidence-based practice promotes the use of

interventions and procedures that have been shown to be safe and effective

through rigorous research. This reduces the risk of harm to patients and enhances

the overall quality and safety of nursing care.

 Advancing Professional Development: Engaging in evidence-based practice

encourages nurses to stay updated with the latest research findings, enhancing

their knowledge and professional growth. It also fosters a culture of lifelong

learning within the nursing profession.

2. Steps in Implementing Evidence-Based Practice:

 Formulating a Clinical Question: The first step in evidence-based practice is

formulating a clear and focused clinical question based on the patient's problem or

the nursing intervention under consideration. The question should be structured

using the PICO framework (Population, Intervention, Comparison, Outcome) to

guide the search for relevant evidence.

 Conducting a Literature Search: Once the clinical question is identified, nurses

conduct a systematic search of the literature using databases and other reliable
 sources to find relevant research evidence. This includes peer-reviewed journals,

systematic reviews, meta-analyses, and clinical practice guidelines.

 Appraising the Evidence: After identifying relevant research articles, nurses

critically appraise the evidence to evaluate its validity, relevance, and

applicability to the clinical question. This involves assessing the study design,

sample size, methodology, and statistical analysis to determine the quality and

strength of the evidence.

 Synthesizing the Evidence: Nurses analyze and synthesize the findings from

multiple research studies to develop a comprehensive understanding of the

evidence. This includes comparing and contrasting the results, identifying patterns

or consistencies, and determining the overall strength of the evidence.

 Integrating the Evidence: Based on the synthesis of the evidence, nurses integrate

the findings into their clinical decision-making process. They consider the

patient's unique circumstances, preferences, and values, along with their own

clinical expertise, to develop an individualized care plan.

 Evaluating Outcomes: Nurses implement the evidence-based intervention and

closely monitor the patient's response. They collect data on outcomes, evaluate

the effectiveness of the intervention, and make adjustments as necessary. This

step contributes to the ongoing cycle of evidence-based practice, as outcomes are

assessed and used to inform future practice decisions.

3. Barriers and Facilitators of Evidence-Based Practice:

 Barriers: Some common barriers to implementing evidence-based practice in

nursing include time constraints, lack of access to research literature, limited

 skills in critically appraising research, resistance to change, and organizational

culture that does not prioritize evidence-based practice.

 Facilitators: Organizations can support evidence-based practice by providing

resources, promoting a culture of inquiry, and offering training and mentorship to

nurses. Collaboration between nurses, researchers, and educators can also

facilitate the integration of research evidence into practice.

4. Ethical Considerations: Nurses must consider ethical principles when implementing

evidence-based practice. This includes obtaining informed consent from patients,

ensuring patient confidentiality, respecting patient autonomy, and considering the

potential risks and benefits of interventions based on the available evidence.

Evidence-based practice is a continuous process that requires ongoing learning, critical thinking,

and integration of research findings into nursing practice. By incorporating