Nursing Care Plan Including Diagnosis and Intervention.pdf

Nursing Care Plan Including Diagnosis and Intervention.pdf

1. 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.

2. 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.

3. 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:

4. 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.

5. 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

6. · 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

7. · 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:

CLIENT INITIALS:ROOM #DOB:AGE
GENDER
:
ADMISSIO
N DATE:CODE STATUS:ALLERGIES:
MARITAL
STATUS:
OCCUPATIO
N
(FORMER):
MEDICAL DX:
CHIEF
COMPLAINT
:
PAST HISTORY
(SURGERY/PROCEDURE
S) WITH DATES

8. ORDERS
RATIONAL
E (Why is
this ordered
for this
client???)
EXAMPLE: DIET
2 g Sodium
diet with
nectar thick
liquids only
Sodium is
restricted due
to edema in
the bilateral
lower
extremities
and nectar
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

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

9. 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
TESTS:
DATERESULTS
REASON FOR TESTING AND
IMPLICATIONS FOR NURSING CARE

LAB
TEST
DATERESULTS
NORMS
REFERENCE
RANGES
IMPLICATIONS FOR NURSING CARE
(WHAT S&S I SHOULD BE AWARE OF
AND WHAT YOU CAN DO TO HELP
IMPROVE AN ABNORMAL RESULT?)

10. GROWTH and DEVELOPMENT: (see pages 378-379 Taylor, Lillis and White) or (Erikson’s
Stages of Development)
CLIENT’S DEVELOPMENTAL STAGE ACCORDING TO
HAVIGHUSRT
TASKS OF THIS
STAGE:



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 NameNormal Dosage RangesContraindicationsCoreg (carvedilol)

3.125 mg – 50 mg BIDAsthma, heart block
Pharmacotherapeutic ClassDosage, Route & FrequencyAdverse Reactionsβ-adrenergic blocker

6.25 mg p.o. BID
Bradycardia, CHF,
thrombocytopenia,
hyperglycemia, bronchospasm
Why this Patient Receives this
Med
Effects of the Med on the
Client
Nursing Considerations and
Teaching
He has a history of hypertension
but has been taking Coreg for 2
years to control his hypertension

BP’s for past 3 days have
been 128/78, 132/72, 138/80

How is this medication
impacting your client??B/P
readings, lab results, pain
management, etc……..
Do not discontinue abruptly or
before surgery
Caution with Upper airway
dysfunction
Rise slowly to minimize
orthostatic hypotension, check
B/P and heart rate prior to
administration

11. Take before meals

#1 Brand Name and Generic
Name
Normal Dosage RangesContraindications



Pharmacotherapeutic ClassDosage, Route & FrequencyAdverse Reactions


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




#2 Brand Name and Generic
Name
Normal Dosage RangesContraindications



#3 Pharmacotherapeutic Class
Dosage, Route and
Frequency
Adverse Reactions



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




#4 Brand Name and Generic
Name
Normal Dosage RangesContraindications



Pharmacotherapeutic ClassDosage, Route and Adverse Reactions

12. Frequency


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




#5 Brand Name and Generic
Name
Normal Dosage RangesContraindications



Pharmacotherapeutic Class
Dosage, Route and
Frequency
Adverse Reactions



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




# 6 Brand Name and Generic
Name
Normal Dosage RangesContraindications



Pharmacotherapeutic Class
Dosage, Route and
Frequency
Adverse Reactions



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

13. #7 Brand Name and Generic
Name
Normal Dosage RangesContraindications



Pharmacotherapeutic Class
Dosage, Route and
Frequency
Adverse Reactions



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




#8 Brand Name and Generic
Name
Normal Dosage RangesContraindications



Pharmacotherapeutic Class
Dosage, Route and
Frequency
Adverse Reactions



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




#9 Brand Name and Generic
Name
Normal Dosage RangesContraindications



Pharmacotherapeutic Class
Dosage, Route and
Frequency
Adverse Reactions

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




#10 Brand Name and Generic
Name
Normal Dosage RangesContraindications



Pharmacotherapeutic Class
Dosage, Route and
Frequency
Adverse Reactions



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




#11 Brand Name and Generic
Name
Normal Dosage RangesContraindications



Pharmacotherapeutic Class
Dosage, Route and
Frequency
Adverse Reactions



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

15. #12 Brand Name and Generic
Name
Normal Dosage RangesContraindications



Pharmacotherapeutic Class
Dosage, Route and
Frequency
Adverse Reactions



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

DATE / TIME
(TYPE HERE)



Sample Narrative Note --- Head to Toe format

16. Temp: 98.6Apical HR: 72Resp: 16BP 128/62Ht: 5’10”Wt: 145
12/22/2010
1400
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.
Lungs clear bilaterally to auscultation. Tracheostomy dressing clean, dry, and
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 FINDINGSPATIENT VARIATIONS/ABNORMALSCOGNITION/NEUROLOGICAL (SAMPLE)
Alert and oriented x3, recent and remote
memory intact. Denies any numbness or
tingling to extremities”
(SAMPLE) “Fine resting tremor of left hand

SKIN



SENSORY
Wound measurements and complete
description if available at the very least
Document dressing including the type of
dressing and description of condition!

17. BREASTS -DEFERRED.
RESPIRATORY –
(Include ventilator settings as indicated in
narrative note)


CARDIOVASCULAR
Include any vascular access device, IV lines,
AV fistulas, perma -cath lines, etc.


ABDOMEN –
.
Include any enteral feedings here and route

BOWEL CONTINENCE? LAST BM? BOWEL
PLAN?
MUSCULOSKELETAL -



GENITOURINARY -
URINARY CONTINENCE? TOILETING
PLAN?


PELVIC -
DEFERRED.

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!

18. #
List the Client
problem
An appropriate
Nursing Diagnosis
stem
(REFER TO YOUR
NURSING
DIAGNOSIS LIST)
Related to part of the
statement (This is
individual to your
client)
As evidenced by part of the
statement (This is
individual to your client)
REMEMEBR THIS IS
NOT USED IN A “Risk
For” diagnosis
1
SAMPLE: Reports
severe pain in the
right hip.
“Acute Pain”
“related to” fractured
right hip
“as evidenced by” verbal
report of pain rated at an 8
on a scale of 0 –to 10.
2
SAMPLE:
Complete bed rest
“Risk for Impaired
skin integrity”
“related to “
immobility
NONE it is a “Risk for”
diagnosis so there is no
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.

ASSESSMEN
T
(Data that
directly
pertains to the
above nursing
diagnosis)
OUTCOME
STATEMEN
T
(Patient
centered,
realistic,
specific,
measurable,
target time)
INTERVENTIONS
(Individualized,
specific, frequency)
Minimum of 4-5
interventions per plan
SCIENTIFIC
RATIONALE
(Supporting statement
from text or other
source, cite source)

EVALUATIO
N OF
OUTCOME
(Met, partially
met, unmet,
unknown by
target time)
SUBJECTIVE SHORT 1. Educate the client on 1. “There are many ways Short Term

19. DATA: “My
right hip hurts
me so much
every time I
move. I am so
afraid to start
physical
therapy”
TERM: Client
will report
pain level
rated at a 3 or
lower 30
minutes after
pain
medication
taken
the importance of pain
relief to enhance her
rehabilitation efforts
and include education
on various types of
methods to relieve pain.


2. Encourage client to
express any questions or
concerns she may have
regarding pain
management methods to
alleviate anxiety and
fears.



3. Educate the client on
her responsibility to
honestly report pain
when it occurs as well
as reporting if the
current pain
management is effective
or ineffective for
providing her pain relief

4. Provide for
alternative/complement
ary measures of pain
relief, such as, reduce
lighting and noise,
soothing music, pet
therapy, massage, and
hot/cold packs
according to client
to manage pain. In
addition to
pharmacologic and non-
pharmacologic
measures, simple
nursing interventions can
alter patients’ pain
experience and speed
their recovery.” Taylor,
Lillis and White pg.
1168.

2. “Common fears
include a loss of control
and embarrassment by
being unable to deal with
pain maturely… The
patient may view the
need of for medication
as a sign of weakness or
may fear addiction or
loss of effectiveness at a
later date.” Taylor, Lillis
and White pg. 1169.


3. “As a patient
advocate, ensure that a
strong emphasis on the
need for aggressive,
individualized strategies
that can minimize or
eliminate acute pain and
improve patient
outcomes. Preventing
pain is easier then
treating it once after it
occurs.” Taylor, Lillis
and White pg. 1178.
Goal: Met; pain
was rated at a 2
on a scale of 0
to 10 after
administration
of Vicodin.





Long Term
Goal. In
progress

20. 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
independently.
2 daughter live
nearby and
visit often.
History of a
fall while out
shopping 1 ½
weeks ago.
Right hip
surgically
repaired 7 days
ago. Surgical
dressing to
right hip is
clean, dry and
intact.
Circulation,
motion and
sensation intact
LONG
TERM: Client
will report
pain level of 2
or less using
ibuprofen
with
alternative
pain control
methods by
discharge.

21. 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.

22. 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
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:
ASSESSMENT
(Data that directly
pertains to the
above nursing
diagnosis)
OUTCOME
STATEMENT
(Patient centered,
realistic, specific,
measurable,
target time)
INTERVENTIONS
(Individualized,
specific, frequency)
SCIENTIFIC
RATIONALE
(Supporting
statement from
text or other
source, cite
source)

EVALUATION
OF OUTCOME
(Met, partially
met, unmet,
unknown by target
time)
SUBJECTIVE
DATA:
SHORT TERM:
OBJECTIVE
DATA:
LONG TERM:

23. 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
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:

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

EVALUATION
OF OUTCOME
(Met, partially
met, unmet,
unknown by target
time)
SUBJECTIVE
DATA:
SHORT TERM:
OBJECTIVE
DATA:
LONG TERM:
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

24. 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:

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

EVALUATION
OF OUTCOME
(Met, partially
met, unmet,
unknown by target
time)
SUBJECTIVE
DATA:
SHORT TERM:
OBJECTIVE
DATA:
LONG TERM:
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
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:

25. 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.

26. 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:

27. 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:

28. 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:

29. Student Name:Clinical Date:Site:

SectionGrading Criteria
Satisfactory Or
Unsatisfactory
Comments,
Kudos,
Things to
Improve for
Next Time
10 points
Patient Demographics,
Diagnoses, Surgeries,
Orders, Rehab, IV,
Imaging and Lab
Page 1 fully and correctly
completed 5 pts
Page 2 fully and correctly
completed 5 pts

_/5___
_/5___


20 points
Medications


Medication Trade Name 2 pts
Medication Generic Name 2 pts
Pharmacological Classification 2 pts
Normal Dosage Range 2 pts
Dose ordered 2 pts
Route and Frequency 2 pts
Contraindications 2 pts
Adverse Effects/Reactions 2 pts
Nursing Considerations & Teaching
2 pts
(Legible or typed) 2 pts
/ 2
/ 2
/ 2
/ 2
/ 2
/ 2
/ 2
/ 2
/ 2
/ 2
_/20__

10 points
Narrative Notes
Head-to-Toe
Assessment
Narrative note is in Head to Toe
order
Head-to-toe assessment documented
Abnormal results noted 10 pts
Nursing Care Plan and Diagnosis
for Chronic Pain

___/10_

30. 60 points (either a
Concept Map or a
Patient Care Plan)
Concept Map
Correct Medical Diagnosis 15 pts
Pathophysiology 15 pts
Key Assessments 15 pts
At least 3 problems identified 15 pts
Nursing Care Plan and Diagnosis
for Chronic Pain

____/60

OR

60 points (either a
Concept Map or a
Patient Care Plan)
Patient Care Plan

3 nursing diagnoses Related to” “As
evidenced by” 18 pts
2 Outcomes specific, measurable,
timed 8 pts
4-5 Interventions are logical,
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

31. 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

32. Pain masking the face
Consideration of muscular tone
Nursing care plan for pain with intervention and rationale
Nursing interventionRationale
Assessment of pain characteristics. ex.
Quality, severity, location, onset, duration,
precipitating and relieving factors
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.
Screening for signs and symptoms related
to pain.
Some people deny the sensation of pain even though
it is present. Paying attention to signs associated with
pain can help the nurse assess pain.
A patient with acute pain may have elevated blood
pressure, heart rate, temperature, be agitated, and
have difficulty concentrating.
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.
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.
Evaluate the patient’s response to pain and
pain management strategies.
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.
Assess patient’s expectations for 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.
Anticipate the need for pain relief.
The most effective way to address pain is to prevent
it. Early intervention can reduce the total amount of
analgesics needed.
Eliminate additional stressors or
discomfort whenever possible.
Patients may experience exaggeration of pain or
diminished ability to tolerate painful stimuli if they
experience additional stress from environmental,
intrapersonal, or intrapsychic factors.
Provide rest periods to promote comfort,
sleep, and relaxation.
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.
Determine the appropriate method for pain
relief.
Unless contraindicated, all patients with acute pain
should receive a nonopioid analgesic around the

33. clock.
Hot or cold compress
Heat reduces pain by improving blood flow to the
area and reducing pain reflexes. Cold reduces pain,
inflammation, and spastic massage by decreasing the
release of pain-inducing chemicals and slowing the
transmission of pain impulses.
Massage of the painful area
Increases endorphin levels and decreases tissue
edema. This intervention may require another person
to perform the massage.
Administer analgesics as ordered by a
physician, evaluate their effectiveness, and
observe signs and symptoms of side
effects.
Analgesics are absorbed and metabolized differently
by patients, so their effectiveness must be assessed
by the patient individually. Analgesics usually have
side effects that range from mild to life-threatening.
Notify the physician if interventions are
unsuccessful or if current symptoms
represent a marked change from the
patient’s previous pain experience.
Patients who request pain medications at shorter
intervals than prescribed may actually require a
higher dose or stronger analgesics.
Anticipatory education about the causes of
pain and appropriate measures for
prevention and relief.
Knowing what to expect can help patients develop
effective coping strategies for pain management.
Patients need to learn the importance of reporting
pain early to achieve more effective pain relief.
The patient should learn how to effectively
discontinue the medication dose in relation
to potentially unpleasant activities and
avoidance of pain spikes.
Patients must learn to use pain relief strategies to
minimize the pain experience.
Assist the patient and family in identifying
lifestyle changes that can contribute to
effective pain management. Guide the
patient to plan activities during the times
when pain is at its greatest relief.
Changes in work routine, household responsibilities,
and home environment may be necessary to promote
more effective pain management. Ongoing support
and guidance for the patient and family will increase
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,


34. 


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!
- A clinical judgment that helps nurses determine the plan of care for
their patients

frame.
 - Actions to be taken to achieve expected
outcomes and reasoning behind them.

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,


o
o
o
o
o

o
o

35. o
o

o





Diagnostic testing
o
o
o
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. - Patient problem present during a nursing assessment is known as a
problem-focused diagnosis
2.- Risk factors require intervention from the nurse and healthcare team prior to a real
problem developing
3. - Improve the overall well-being of an individual, family, or
community
4. - 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.
interventions needed to care for the patient.

36. 2. - Possible reasons for the problem or the conditions in which it
developed
3.- 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,





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,






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

37. 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:






Health system interventions
Some interventions will be patient or diagnosis-specific, but there are several that are completed
each shift for every patient:


Fall prevention

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,



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.

38. 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,





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:

39. 1.Importance of Evidence-Based Practice:

clinical decision-making, nurses can provide care that is more effective, safe, and
aligned with best practices, leading to improved patient outcomes.

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.

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 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.

conduct a systematic search of the literature using databases and other reliable

40. sources to find relevant research evidence. This includes peer-reviewed journals,
systematic reviews, meta-analyses, and clinical practice guidelines.

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.

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.

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.

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:

nursing include time constraints, lack of access to research literature, limited

41. skills in critically appraising research, resistance to change, and organizational
culture that does not prioritize evidence-based practice.

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