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
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Pain Assessment
- Conduct pain assessment according to protocol on admission, quarterly, and as needed
- Assess for pain every shift and as needed (PRN)
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Medication Management
- Administer pain medications as ordered
- Notify MD for any persistent pain not relieved by medications
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Therapeutic Interventions
- Consult physical therapy (PT) and occupational therapy (OT) as needed
- Encourage use of non-pharmacological interventions (e.g., cold compress) as needed
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Patient and Family Involvement
- Encourage family participation, if available, in the patient's pain management
- Educate the patient and family about pain management techniques
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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
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Pain Assessment
- Regular pain assessments ensure timely identification and management of pain, improving the patient’s comfort and quality of life.
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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.
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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.
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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.
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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
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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.
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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.
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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.
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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.
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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.
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