NURSING PROCESS CARE PLAN Alteration in Comfort/ Pain

PATIENT'S INITIALS: ________________ DATES OF CARE: ___________________ STUDENT'S NAME ________________________

ASSESSMENT SUPPORTIVE DATA S: Pt stated the she is So sore in the mornings that she doesnt want to do anything. Pt a so said that sometimes the !ain "ree!s #! on her and she doesnt re"ogni$e it #nti shes "#r ed #! in %ed. Pain on wa&ing ' ()*+, O: --yo. /0P 11203' 4R 2+ RR 5) O6' 5 days !ost o!* 7PDrain ! a"ement 8#ngs " ear %i 9 ant0!ost 4y!oa"ti:e /S 6; Pt g#arding and grima"ing9 4o ding <oms hand to sit #!. D=: Peritonitis R#!t#red a!!d6.

ANALYSIS >URSI>? DIA?>OSIS A teration in @omAort0 Pain r0t Disease !ro"ess9 s#rgi"a in"ision9 and tiss#e damage

PLANNING @8IE>T ?OA8S0 OUT@O<E @RITERIA Patients s#%Be"ti:e !er"e!tion oA a tered "omAort0 !ain de"reases. . Ae% ST?: 1. Patients rating on !ain s"a e within 1 hr oA inter:ention. 5. Diminished or A%sent non:er%a indi"ators (grima"e9 a%d g#arding, within 1hr oA inter:ention. 8T?: 1. @ ient wi :er%a i$e 5 non*medi"ation ways oA !ain re ieA %y dis"harge. 5. @ ient wi as& Aor medi"ations when she Airst noti"es !ain in"reasing9 or when she &nows she has a"ti:ity s"hed# ed %y dis"harge.

IMPLEMENTATION >URSI>? A@TIO>S 1. Ci !erAorm %ase ine assessment at the %eginning oA ea shiAt with a!!ro!riate !ain s"a e. 5. Reassess " ient D1*5h. S@IE>TI.I@ PRI>@IP8ES0 RATIO>A8E 1. Ci he ! determine the eAAe"ti:eness oA inter:entions. 5. Ci !re:ent " ient Arom s#AAering Arom !ain Aor !ro onged amt oA time. '. S! inting red#"es !ain on mo:ement9 "o#ghing9 and dee! %reathing. ;. InAormation he !s minimi$e an6iety9 whi"h "an e6a"er%ate dis"omAort. +. A"ti:ities !ro:ide distra"tions Arom !ain. 3. <inimi$e !ress#re on %ones9 Boints9 m#s" es and s&in.

EVALUATION O/SERVATIO>S0 @O>@8USIO>S Patient started oAA day s ee!ing in ti 1)am and not wanting to get OO/. Pain ' ()*+,. ') mins aAter re"ei:ing I%#!roAen 3))mg !t was m#"h more "oo!erati:e and re a6ed. Re!orted Pain oA 1 ()*+,. Ce ta &ed a%o#t the im!ortan"e oA !ositioning9 s! inting9 &ee!ing %#sy9 and a so the medi"ation o!tions she had a:ai a% e. Pt :er%a i$ed 5 non* medi"ation re ieA meas#res to me. She too& a na! aAter #n"h and re!orted her !ain in"reasing to a 5()*+,. Dis"#ssed as&ing Aor medi"ation when she needs it or %eAore she &nows she has an a"ti:ity "oming #!9 or wi %e s ee!ing Aor any ength oA time. A so ta &ed a%o#t indi"ators that her !ain meds were wearing oAA 9 or

'. Instr#"t Pt in methods to s! int a%d. ;. E6! ain a !ro"ed#res

+. Pro:ide Pt with games9 %oo&s9 mo:ies9 and !hone. 3. Show Pt :ario#s !ositions she may #se to red#"e !ain and dis"omAort.

A teration in @omAort0 Pain r0t Disease !ro"ess9 s#rgi"a in"ision9 and tiss#e damage

her !ain e:e was %eginning to in"rease. 4er Pain e:e de"reased to a )()*+, aAter re"ei:ing '5+mg oA A"etamino!hen. ST? met and "ontin#ing. 8T?: Partia y met and "ontin#ing. >eeds re:ision "on"erning %athing "are oA 7PDrain re ated to "omAort.