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Nur 2032C Chronic Pain Care Plan
- Course
- NUR 2032C
- Institution
- Keiser University
Care Plan-4 - A completed care plan for nursing diagnosis of chronic pain
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KEISER UNIVERSITY – Port Saint Lucie Campus BSNNUR2032C Care Management I
Daily Care Plan
Student name: Sue Falanga Current date: 10/27/22
Patient initials: JK Age: 81 Sex: M Dates care given:
ADMISSION DIAGNOSIS:
The patient is an 81-year-old male, married, and lives in a one-story home with his wife, in Vero Beach. The patient
began experiencing pain, first in 2018, following spinal cord surgery. The pain is centered in his lower back heightened
when ambulating. Six months ago, the patient had left hip surgery and because of the increased pain levels, three
months ago, the patient had 4 needles put into his lower back to kill the nerves and help alleviate some of his pain.
However, this was short-lived only working for a couple of weeks. A little under four weeks ago, the patient was
admitted to the hospital to undergo a cholecystectomy. While recovering at Cleveland clinic medical hospital, he
contracted an infection, sepsis. During his month-long stay, he was unable to get out of bed. This made things worse for
the patient, stating that he has increased difficulty and pain since being in the hospital. The patient was transferred to
Encompass rehabilitation center via a stretcher and moved into the bed using a slide board, yesterday, 10/27/22, to
begin receiving an aggressive form of physical therapy.
PATHOPHYSIOLOGY/POTENTIAL COMPLICATIONS:
The gallbladder is a small organ located on the underside of the liver. Its primary purpose is bile storage. The liver makes
bile, and the gallbladder stores the extra bile made by the liver. It releases bile when you eat a meal with fats that need
to be digested. According to the Mayo Clinic, laparoscopic cholecystectomy is the most common type of gallbladder
removal surgery performed. It’s a minimally invasive surgery. Some symptoms that may indicate the need for gallbladder
removal includes; sharp pain in the right upper portion of your abdomen, which can radiate to the middle of your
abdomen, right shoulder or back, fever, nausea, and vomiting. The gallbladder is removed via a single, large open
incision in the abdomen. This procedure is to provide permanent relief to a person with gallstones and
other problems associated with the gallbladder. Gallstones are formed mainly due to over secretion of cholesterol by
liver cells or impaired emptying of the gallbladder. Although gallbladder removal is a common and safe procedure with
few complications, it is still surgery and some risks associated with the procedure are: adverse reaction to the
anesthesia, excessive bleeding, blood clots, damage to blood vessels, heart problems (rapid heart rate, heart attack, or
heart failure), infection, and injury to the bile ducts or small intestine.
PERTINENT PREVIOUS MEDICAL HISTORY (PMI):
Hip replacement, knee surgery, aortic valve replacement, history of UTIs, diabetes, spinal surgery.
COURSE OF HOSPITALIZATION:
On 10/4/22 was admitted to the hospital to have a cholecystectomy removed, after surgery, while still at the hospital
recovering, he contracted an infection, sepsis. He was then transported on 10/26/22 to Encompass to get physical
therapy.
Cardiac: GU:
Subjective Subjective
5/2019
pg. 1
, KEISER UNIVERSITY – Port Saint Lucie Campus BSN
NUR2032C Care Management I
1. Patient states he had an aortic valve replacement 4 1. Patient states he has no burning when peeing.
yrs. Ago. 2. Patient states he has a history of UTI’s.
2. Patient states he had 2 TIA’s in last 10 years. 3. Patient states he and his family have no kidney disease.
3. Patient states lost his mom from a heart attack. 4. Patient denies incontinence, did have a catheter, was
4. Patient has coronary artery disease. removed this morning.
Objective Objective
1. Capillary refill less than 2 seconds. 1. Color slightly dark.
2. Irregular heart rhythm heard. 2. No smell.
3. S1 present, louder at the apex, S2 present, louder at 3. Input 450ml out 300ml.
the base. 4. No distension in abdomen.
4. Extra heart sound heardS3 or S4, possible murmur.
M/S:
Respiratory: Subjective
Subjective 1. Patient states Lower back pain, increased when walking.
1. Patient states no history of chest pains. 2. Patient states knee & joint stiffness, in am.
2. Patient smoked 1 pk daily x 50 years, quit 15yrs. ago. 3. Patient states he had 2 falls within the year.
3. Patient states he uses a CPAP. 4. Patient states he had a knee replacement few years ago.
4. Patient states he gets short of breath when walking. Objective
Objective 1. Winces when lower back is palpitated.
1. RR 16, unlabored breathing, symmetrical expansion. 2. Gait is slow and unsteady.
2. No lumps, masses, or tenderness when palpitating. 3. Bilateral arm rotation, abduction, and adduction.
3. Bilateral breath sounds clear. 4. Patient has equal strength in lower extremities.
4. No coughing or sputum was noticed while in room.
Skin:
Neurological: Subjective
Subjective 1. Patient states he had skin cancer twice.
1. Patient reports dizziness after PT. 2. Patient states a family history of skin cancer, mother’s side.
2. Patient states he’s nearly blind in left & perfect in 3. Patient states his skin is dry at times.
right eye. Objective
3. Patient states no history of blurry vision 1. Capillary refill less than 3 sec.
4. Patient states no history of headaches. 2. Three small bruises on rt arm.
Objective 3. Skin pink, warm to the touch.
1. A&Ox4 4. No abnormal growths, lesions, or tenderness.
2. Unsteady gait.
3. Reflexes intact. GI:
4. White sclera, PERRLA Subjective
4. Speech is fluent and appropriate. 1. Patient states last bowel movement was yesterday.
2. Patient states he has a decreased appetite.
Psychosocial: 3. Patient states no history of
Objective 4. Patient states he does not have trouble swallowing.
1. Dressed well, clean, and showered. Objective
2. Cooperative. 1. Abdomen slightly curved, no apparent masses.
3. Follows commands without difficulty. 2. Bowel sounds present, no bruits.
4. Appears stated age. 3. Sounds heard in RL and RU Quadrants.
4. Ate only ¼ of breakfast.
5/2019
pg. 2
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