Care Plan for Pain Management

Care Plan for Pain Management

Category / Primary Body System

• Pain Management / Nervous System

Problem

• Patient has potential for alteration in comfort due to pain.

Goal

• Patient will not experience pain or will maintain an acceptable level of pain (per patient) daily for 90 days.

Plan/Approach

1. Pain Assessment

   • Conduct pain assessment according to protocol on admission, quarterly, and as needed
   • Assess for pain every shift and as needed (PRN)

2. Medication Management

   • Administer pain medications as ordered
   • Notify MD for any persistent pain not relieved by medications

3. Therapeutic Interventions

   • Consult physical therapy (PT) and occupational therapy (OT) as needed
   • Encourage use of non-pharmacological interventions (e.g., cold compress) as needed

4. Patient and Family Involvement

   • Encourage family participation, if available, in the patient's pain management
   • Educate the patient and family about pain management techniques

5. Monitoring and Documentation

   • Monitor patient for non-verbal expressions of pain (e.g., grimacing, moaning, guarding)
   • Document the patient’s pain levels, interventions used, and response to treatment

Rationale

1. Pain Assessment

   • Regular pain assessments ensure timely identification and management of pain, improving the patient’s comfort and quality of life.

2. Medication Management

   • Administering pain medications as prescribed ensures effective pain relief and prevents breakthrough pain.
   • Promptly notifying the MD of persistent pain allows for adjustments to the pain management plan.

3. Therapeutic Interventions

   • PT and OT consultations provide additional strategies for pain management and functional improvement.
   • Non-pharmacological interventions complement medication therapy and provide holistic pain relief.

4. Patient and Family Involvement

   • Involving the patient and family in pain management promotes adherence to the care plan and provides emotional support.
   • Education empowers the patient and family to use various pain management techniques effectively.

5. Monitoring and Documentation

   • Monitoring for non-verbal expressions of pain ensures that pain is recognized and managed even if the patient cannot communicate verbally.
   • Documentation helps track the effectiveness of interventions and guides future pain management strategies.

Actions

1. Pain Assessment

   • Conduct a comprehensive pain assessment on admission using a standardized pain scale (e.g., Numeric Rating Scale, Wong-Baker FACES Scale).
   • Reassess pain levels every shift and PRN, documenting the findings.

2. Medication Management

   • Administer prescribed pain medications at scheduled times and PRN, monitoring for effectiveness and side effects.
   • Notify the MD if the patient reports persistent pain despite medication, to adjust the treatment plan as needed.

3. Therapeutic Interventions

   • Arrange PT and OT consultations as needed to develop individualized pain management and functional improvement plans.
   • Encourage and assist the patient in using non-pharmacological interventions, such as applying cold compresses or practicing relaxation techniques.

4. Patient and Family Involvement

   • Encourage family members to participate in care activities and provide emotional support.
   • Educate the patient and family on pain management techniques, including medication schedules, non-pharmacological methods, and signs to watch for in case of worsening pain.

5. Monitoring and Documentation

   • Monitor for non-verbal expressions of pain regularly, especially in patients who have difficulty communicating.
   • Document all assessments, interventions, and patient responses to ensure continuity of care and guide future pain management.