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 pain tool, such as the 0-10 numerical pain rating scale (Akley and Ladwig, 2017, p. 677).
Intervention #2: Obtain and review an accurate and complete list of medications the client is taking or has taken (Ackley and Ladwig, 2017, p. 678).
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 pain (Ackley and Ladwig, 2017, p. 678).
Intervention #4: Describe the adverse effects of unrelieved pain (Ackley and Ladwig, 2017, p. 678).
Intervention #5: Discuss the client's fears of undertreated pain, side effects, and opioid use disorder, and reassure the client that there will be regular assessment and treatment of pain, and assessment for side effects and signs of opioid use disorder (Ackley and Ladwig, 2017, p. 678).
EVALUATION OF INTERVENTIONS:
Evaluation of intervention #1: R.K. was able to report her pain as a 7/10 (This value is made up for the purpose of completing this concept map. I realize that I will never make up numbers or values in real life) and also stated that it felt heavy substernal pressure.
Evaluation of intervention #4: I explained to the patient that unrelieved pain can cause neurohormonal changes, impact the immune system, and can lead to persistent pain syndromes. The patient verbalized understanding of the importance of reporting her pain and stated that she will report her pain whenever it comes on (Ackley and Ladwig, 2017, p. 678).
Evaluation of intervention #5: I talked with the patient about her fear of living with this chest and epigastric pain for the rest of her life. I explained that it can be managed with the appropriate drug therapy as well as healthy eating and exercise and she verbalized that she felt better about the treatment and her future. (This evaluation is made up for the purpose of the concept map. I realize I will never make up information in real life).
SMART GOAL: Priority #2
The patient will verbalize understanding of two benefits of accurate medication reconciliation including prevention of error associated with incorrect medications and prevention of drug to drug interactions without the assistance of the nursing staff or family members by the end of my shift on 4/14/20.
(Ackley and Ladwig, 2017, p. 678).
Goal met. My patient was able to verbalize understanding of the benefits of accurate and complete medication reconciliation as indicated in the previous goal today.