Updated Care Plan for Pain Management

Updated Care Plan for Pain Management

Category / Primary Body System:

Pain Management / Nervous System

Problem:

The patient has potential for alterations in comfort due to pain.

Goal:

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

Plan/Approach:

1. Pain Assessment:

   • Step: Conduct pain assessments according to protocol on admission, quarterly, and as needed.
   • Rationale: Regular pain assessments help in identifying and managing pain effectively.
   • Actions: Utilize standardized pain assessment tools (e.g., Numeric Rating Scale, Wong-Baker FACES) during admission, quarterly reviews, and as the patient's condition changes. Document findings accurately.

2. Routine Pain Checks:

   • Step: Assess for pain every shift (Q shift) and PRN.
   • Rationale: Frequent assessments ensure timely intervention and pain control.
   • Actions: Perform pain assessments at the beginning of each shift and whenever the patient reports pain. Record the intensity, location, and nature of the pain.

3. Medication Administration:

   • Step: Administer pain medications as ordered.
   • Rationale: Proper administration of pain medications is essential for effective pain relief.
   • Actions: Administer prescribed analgesics on schedule and PRN, monitor for efficacy and side effects, and document the administration and patient’s response.

4. Persistent Pain Management:

   • Step: Notify the MD for any persistent pain not relieved by medications.
   • Rationale: Persistent pain requires further medical evaluation and possible adjustment of the treatment plan.
   • Actions: Monitor the patient’s pain levels after medication administration, and promptly report any persistent or escalating pain to the healthcare provider.

5. Therapy Consultations:

   • Step: Arrange PT/OT consultations as needed.
   • Rationale: Physical and occupational therapy can provide additional strategies for managing pain and improving function.
   • Actions: Schedule evaluations with physical and occupational therapists, implement recommended exercises or interventions, and monitor the patient’s progress.

6. Family Involvement:

   • Step: Encourage family participation, if available, in managing the patient’s pain.
   • Rationale: Family support can enhance the patient’s comfort and adherence to pain management strategies.
   • Actions: Educate family members about pain management techniques, involve them in care activities, and encourage their emotional support.

7. Non-Pharmacological Interventions:

   • Step: Use non-pharmacological forms of intervention (e.g., cold compress) as needed.
   • Rationale: Non-pharmacological interventions can complement medication therapy and provide additional pain relief.
   • Actions: Apply cold or warm compresses, encourage relaxation techniques, and provide comfort measures such as positioning and massage. Evaluate and document the effectiveness of these interventions.

8. Non-Verbal Pain Monitoring:

   • Step: Monitor the patient for non-verbal expressions of pain (e.g., grimacing, moaning, guarding).
   • Rationale: Recognizing non-verbal cues is crucial for managing pain in patients who may have difficulty communicating their pain levels.
   • Actions: Observe the patient for signs of pain during routine interactions and care activities. Document observations and take appropriate action to alleviate discomfort.