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Pt initials: MP Pt info: 8 yo Pt weight: 32.5 kg Admit date: 9/18/20 …

- - - - INTERVENTIONS:
        Intervention #1: Assess if the client is able to provide a self-report of pain intensity, and if so, assess pain intensity level using a valid and reliable self-report tool (0-10 scale) (Ackley and Ladwig, 2017, p. 677).
        Intervention #2: Ask the client to describe prior experiences with pain, effectiveness of pain management interventions, and responses to analgesic medications (Ackley and Ladwig, 2017, p. 677).
        Intervention #3: Explain to the client the pain management approach, including pharmacological and nonpharmacological interventions, the assessment and reassessment process, potential side effects, and the importance of prompt reporting of unrelieved pain (Ackley and Ladwig, 2017, p. 678).
        Intervention #4: Regularly reassess the client for the presence of pain and response to pain management interventions, including effectiveness and the presence of adverse effects related to pain management interventions (Ackley and Ladwig, 2017, p. 678).
        Intervention #5: Administer a nonopioid analgesic for mild to moderate pain and add an opioid analgesic if indicated for moderate to severe acute pain (Ackley and Ladwig, 2017, p. 678).
        
        EVALUATION:
        Goal met. After the administration of Acetaminophen 480 mg and the implementation of deep breathing, the patient reported a pain scale of 0/10. This occurred before the end of my shift on 9/19/20. One intervention I could have added to reach my goal was I could have implemented a distraction technique or helped her with guided imagery.
- - - - INTERVENTIONS:
        Intervention #1: Consider using healing touch and other mind-body-spirit interventions such as stress control, therapeutic massage, and imagery (Ackley and Ladwig, 2017, p. 907).
        Intervention #2:Client should be allowed to shower after surgery to maintain cleanliness if not contraindicated (Ackley and Ladwig, 2017, p. 908).
        Intervention #3: Promote early ambulation and deep breathing (Ackley and Ladwig, 2017, p. 908).
        Intervention #4: Encourage client to use prayer as a form of spiritual coping if this is comfortable for the client (Ackley and Ladwig, 2017, p. 908).
        Intervention #5: Teach imagery and encourage distraction for children for postsurgical pain relief (Ackley and Ladwig, 2017, p. 908).
        
        EVALUATION:
        Goal met. My patient's fever dropped from 38.1 (at 0800) to 36.7 (at 1200), rated her pain at a 0/10 (at 1200), and an expected discharge date was set for 9/23/20. This all occurred before the end of my shift on 9/19/20. One intervention I could have added to reach my goal was I could have assessed my patient's nutritional habits more closely as good nutrition aids wound healing and may decrease the time needed in the hospital.
- - - - INTERVENTIONS:
        Intervention #1: Assume a facilitator role versus authority role when engaging clients seeking health-related knowledge (Ackley and Ladwig, 2017, p. 588).
        Intervention #2: Refer clients to interactive and Web-based technological resources as appropriate (Ackley and Ladwig, 2017, p. 588).
        Intervention #3: Consider the context, timing, and order of how information is presented (Ackley and Ladwig, 2017, p. 585).
        Intervention #4: Use client-centered approaches that engage clients and caregivers as active versus passive learners (Ackley and Ladwig, 2017, p. 585).
        Intervention #5: Guide children and adolescents to credible information about their condition (Ackley and Ladwig, 2017, p. 585).
        
        EVALUATION:
        Goal met. After giving the patient's mom information from lexicomp about each medication, she was able to teach back what medications her daughter is on and the action of each one before the end of my shift on 9/19/20. One intervention I could have added to reach my goal was I could have taught the information earlier in the day and then had time to reinforce the learning through repetition and follow-up.