Individual Nursing Care Plan 3 PDF

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Summary

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Nursing care plan
nursing diagnosis...

Description

Nursing Care Plan Form Nursing Student Name:

Date: August 19,2020

Patient Identifier: D.W.

Patient Medical Diagnosis Endometriosis

Nursing Diagnosis: Chronic pain r/t pelvic tenderness during onset of menses as evidenced by patient stating a 6/10 pain. Assessment Data (Include at least four data points listed; 2 subjective and 2 objective. Incorporate them into the nursing diagnosis)

Subjective  Patient states “sex is so painful; I don’t want to do it”.  Patient has a history of menorrhagia.  Patient states that she “feels like I can’t do anything when I have my period”. Objective  Patient states pain is a 6/10 on the numeric scale.  Small masses were palpable on pelvic/abdominal area during examination.

Goals & Outcome Statements (Two statements are required for each nursing diagnosis. Must be Patient and/or family focused; must be in SMART format.)

1. Patient will verbalize the use of 1 or more relaxation skills/activities by end of the shift (1800). 2. Patient will state pain is a 2/10 or below by end of the shift (1800).

Nursing Interventions

Rationale

Outcome Evaluation

(List at least three nursing interventions for each goal & outcome statement.)

(Provide reason why intervention is indicated or therapeutic; provide references.)

(Was goal met? How do you know? How would you revise the plan of care according the patient’s response to current plan?)

1. The nurse will encourage the patient to use the chaplain and brochures having information about women’s groups. 2. The nurse will teach the patient to maintain a journal, tracking their pain levels, factors that onset it or decrease it and effectiveness of pain management interventions. 3. The nurse will educate the patient the importance of physical activity, especially yoga.

1. One way to cope with chronic pain and the psychosocial factors that come with it is through support groups. Support groups can give patients a place to discuss their stresses, become more educated on their disease and be a resource for a patient (Mohammad W.F., Hassan H. E., 2019). 2. Keeping a journal allows the patient to reduce catastrophizing their symptoms and allows them to understand what treatments are working and ones that are not. This can let the patient prepare questions for their HCP, nurse and support group

The subjective goal was met. The patient was able to verbalize 2 activities to do to achieve relaxation. 1. The goal was partially met. The patient used the brochures but did not want to speak to the chaplain. Instead nurse will print a list of websites containing women support groups near the patient’s residential address to give to the patient. 2. The goal was met. The patient’s husband bought a journal and she has

1. The nurse will administer analgesics PRN for continuous pain

management. The nurse will provide nursing care during peak of analgesics such as ambulation or showering. 3. The nurse will give ice pack to the patient to place on abdomen for 20 minutes on and 20 minutes off. 2.

(Ackley B., et. al, 2020). 3. Yoga helps stretch the body, has meditative breathing exercises and is effect in pelvic pain management. Yoga gives the ability for patients to become self-aware in their pain and can build selfesteem (Buggio L., et. al., 2017).

1. Around the clock analgesics can help reduce breakthrough pain and help the patient feel more relieved (Ackley B., et. al, 2020). 2. Patient will be more willing to and can perform activities without the fear of pain (Ackley B., et. al, 2020). 3. The use of ice can help numb the area, reduce pain by using the big A fibers to out beat the small C fibers when detecting senses (Ackley B., et. al, 2020).

started logging in the information taught to her and tracking her pain levels using the numeric scale. 3. The goal was met. The patient was looking up online yoga videos and started practicing breathing practices from them. The objective goal was partially met. The patient stated a 4/10 pain by end of shift. 1. The goal was met. The nurse administered analgesics PRN and assessed and reassessed patients pain scale. 2. The goal was partially met. The patient agreed to 1 of the 3 activities and had asked the nurse to do a bed bath instead of a shower. The nurse will consult with HCP about the strength of analgesics and teach the patient

the importance of regaining full independence. 3. The goal was not met. The patient said the ice pack was too cold and unbearable and took it off immediately. The nurse will place ice pack in 1-2 pillow cases to have a barrier between patient’s skin and actual ice pack and reduce time to 15 minutes on 20 minutes off. References: Ackley B., Ladwig G.B., Makic M., Martinez-Kratz M., Zanotti M. (2020). Nursing Diagnosis Handbook (12th ed.). Elsevier. Buggio, L., Barbara, G., Facchin, F., Frattaruolo, M. P., Aimi, G., & Berlanda, N. (2017). Self-management and psychological-sexological interventions in patients with endometriosis: strategies, outcomes, and integration into clinical care. International journal of women's health, 9, 281–293. https://doi.org/10.2147/IJWH.S119724 Mohammad, F. W., & Hassan, H. E. (2020). Effect of Instructional Supportive Guideline for Improving Women’s Awareness towards Endometriosis. American Journal of Nursing Research, 8(1), 38–47. https://doi.org/10.12691/ajnr-8-1-5...