Nursing Diagnosis: Acute pain related to suspicious findings of a splenic infarction as evidenced by a pain score of 7, facial grimacing, and a flat affect.

QUESTION

Nursing Diagnosis: Acute pain related to suspicious findings of a splenic infarction as evidenced by a pain score of 7, facial grimacing, and a flat affect.

1. Discuss 3 SMART goals related to primary problem

2. Discuss 2-3 interventions

Nursing Diagnosis: Activity intolerance related to pain with movement as evidenced by the patient stating ” the pain goes away when I am lying still, ” and facial grimacing with movement.

1. Discuss 3 SMART goals related to primary problem

2. Discuss 2-3 interventions

ANSWER

Nursing Diagnosis: Acute pain related to suspicious findings of a splenic infarction as evidenced by a pain score of 7, facial grimacing, and a flat affect.

SMART Goals

Specific: The patient will verbalize a decrease in pain intensity from a 7 to no more than 4 on the pain scale within 24 hours.

 Measurable: Pain scores will be documented every 4 hours, with a goal of consistent pain reduction.

Achievable: The patient will demonstrate the use of relaxation techniques, such as deep breathing exercises and guided imagery, as non-pharmacological pain management methods.

Interventions

Pain Assessment: Perform frequent pain assessments every 4 hours or as needed to monitor pain levels accurately.

Pharmacological Management: Administer pain medication as prescribed by the physician and reassess the effectiveness of the medication within 30 minutes.

Non-Pharmacological Pain Management: Teach and encourage the patient to utilize relaxation techniques, such as deep breathing exercises and guided imagery, to complement pharmacological pain management.

Nursing Diagnosis: Activity intolerance related to pain with movement as evidenced by the patient stating “the pain goes away when I am lying still” and facial grimacing with movement.

SMART Goals

Specific: The patient will independently perform activities of daily living (ADLs), such as bathing and dressing, without excessive pain or discomfort within 48 hours.

Measurable: The patient’s ability to complete ADLs without significant pain or facial grimacing will be assessed and documented twice daily.

Achievable: The patient will receive physical therapy consultations to develop a personalized plan to improve mobility and tolerance for ADLs.

Interventions

Pain Assessment:Continuously assess the patient’s pain level, particularly during and after mobility and ADLs, to identify any changes or patterns.

Collaboration with Physical Therapy: Consult with the physical therapy team to develop an individualized plan to improve the patient’s mobility and activity tolerance.

Education: Educate the patient on pacing activities, proper body mechanics, and the importance of consistent pain management to facilitate improved activity tolerance.

These SMART goals and interventions aim to address both the acute pain experienced by the patient and the associated activity intolerance. By combining pharmacological and non-pharmacological pain management strategies and collaborating with physical therapy, the nurse can assist the patient in achieving improved pain control and enhanced functional ability.