Acute Pain Care Plan

Acute pain is one of the most common diagnoses in the nursing field. Building a single care plan is time consuming and takes away from the already minuscule amount of time you have with your patients.  Careplans.com will allow you to leave your paperwork behind and get back to the real reason you became a nurse: to help people!  Using our Careplan Express feature, I created an acute pain care plan that you can easily modify to meet your patients’ individual needs.

Assessment

Subjective: Patient states, “It hurts when I put weight on my left foot.” Reports pain of 7 out of 10.

Objective:  Patient has a one inch laceration on the bottom of her left foot. The area surrounding the laceration is red, warm, and swollen. There is a moderate amount of purulent drainage. Patient is unable to walk without assistance. Patient makes facial expressions indicative of pain while attempting to ambulate.

Diagnosis

Acute Pain related to inflammation and swelling from left foot laceration

Planning/Goals/Outcomes

  1. Patient will have control of pain as evidenced by patient ambulating twenty feet without showing any non-verbal signs of pain by 3/18/2015
  2. Patient will have a decreased level of pain as evidenced by the patient verbalizing pain of 2 or less on a 0-10 scale by 3/18/2015.

Interventions

  1. Provide scheduled opiate pain medication as prescribed. Reassess after 30 minutes.

Rationale: Reassessment is required to determine whether or not the pain medication/dosage is effective enough to manage this patient’s pain.

  1. Provide patient assistance with mobility while ambulating with prescribed cane.

Rationale: Patient will be unsteady while attempting to walk with this injury. A support person is needed to promote safety and to prevent any further injuries to this patient.

Evaluation

  1. Patient verbalized pain was at a 2 during assessment on 3/18/2015.
  1. Patient’s pain is under control as evidenced by patient ambulating twenty feet without showing non-verbal signs of pain on 3/18/2015.

A few things to remember while making an acute pain care plan:

√ Make sure your goals are measurable! There is no need to complicate things. Think of what your patient needs and how you will confirm your nursing interventions were successful.

√ The dreaded rationale! There is no need to compile a list of enormous words and copy lengthy paragraphs taken directly from your medical dictionary. If you chose the intervention, chances are, you know the rationale.  Try explaining why you chose a specific intervention to a co-worker or fellow student.  This will allow you to gain more confidence in your nursing knowledge, as well as give you the exact words to write under each intervention’s rationale.

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