Ashley Young, Chelsea Dempsey, Gina Varacalli, and Roz Henley

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION REASSESSMENT Commented [ADT1]: Very good evaluation of goals and
Goals/Outcomes (For each OF OUTCOMES reassessment
intervention)
Subjective: The Acute pain in GOAL: The 1. Goal was Patient verbalizes Commented [ADT2]: You are missing the 3rd part of the
diagnosis: the “as evidenced by”. You’ve got your nursing
patient reported right forearm patient will have met. pain level of 1 on diagnosis and your etiology but missing the evidence.
pain of 6/10 due due to trauma. improved pain 2. Goal was not a scale of 0/10.
to fall. Fells like control by the end met. Patient only
right forearm is of the day. vocalized utilizing
throbbing. one CAM
1.a. Reassess pain 1.a. technique. He
characteristics Assessment of reported utilizing
pain is the first music therapy.
Objective: OUTCOME: 1.b. Anticipate step in
Taylor tripped 1. The patient the need for pain planning pain Commented [ADT3]: You would want to make this measurable-
for example By 4pm today, the patient reports pain less than a 3 on a
over a hose and reports satisfactory relief management. 0-10 pain scale.
landed on his pain control and The patient is
right arm and decreased intensity 1.c. Teach the most reliable
winced. Heart using the standard patient effective source of
rate is elevated at pain scale by 4pm timing of the information
105 and blood today. medication does about his or
pressure 150/80. in relation to her pain.
Swelling and potentially Eliciting the Commented [ADT5]: For your first outcome, you would like for
your patient to have better pain management: I’m seeing that you are
discoloration in uncomfortable patient’s assessing the pain, you are anticipating the need for pain relief, and
right forearm. activities and the expressed teaching patient effective timeing of meds…but what did you do to
improve the patient’s pain?
prevention of needs allows
peak pain periods. the patient to
2. The patient will be a full Commented [ADT4]: I really like your choice of outcome here.
vocalize three CAM partner in
techniques for pain 2.a. Evaluate the providing pain
management by patient’s response management.
discharge. to pain and pain (Gulanick &
Ashley Young, Chelsea Dempsey, Gina Varacalli, and Roz Henley

management Myers, 2017,

strategies. p.155)

2.b. Relaxation 1.b. One can

exercises, most
biofeedback, effectively
breathing deal with pain
exercises, music by preventing
therapy it. Early
intervention
2.c. Provide may decrease
anticipatory the total
instruction on amount of
pain cues, analgesic
appropriate required.
prevention and (Gulanick &
relief measures. Myers, 2017,
p.157)

1.c. Patients
need to learn
to use pain
relief strategies
to minimize
the pain
experience
(Gulanick &
Myers, 2017,
p.159)
Ashley Young, Chelsea Dempsey, Gina Varacalli, and Roz Henley

2.a. Patient
understands
importance of
recording pain
as soon as
possible. The
patient
understands
that mood,
anxiety,
emotion and
how it can
alter
perception of
pain.
(Gulanick &
Myers, 2017,
p.156)

2.b. These
techniques can
induce states
of physical and
mental
awareness and
tranquility
thereby
reducing
tension
subsequently
reducing pain.
Ashley Young, Chelsea Dempsey, Gina Varacalli, and Roz Henley

(Gulanick &
Myers, 2017,
p.158)

2.c.
Knowledge
about
expectations
helps the
patient develop
effective
coping
strategies for
pain
management.
(Gulanick &
Myers, 2017,
p.158)
Ashley Young, Chelsea Dempsey, Gina Varacalli, and Roz Henley

Reference

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: diagnoses interventions, & outcomes. (9th). St. Louis: Elsevier. Commented [ADT6]: Missing the state