Ncp Alteration In Comfort/ Pain

NURSING PROCESS CARE PLAN Alteration in Comfort/ Pain PATIENT'S INITIALS: ________________ DATES OF CARE: ___________________

ASSESSMENT SUPPORTIVE DATA S: Pt stated the she is “So sore in the mornings” that she doesn’t want to do anything. Pt also said that sometimes the pain creeps up on her and she doesn’t recognize it until she’s curled up in bed. Pain on waking 3 (0-5) O: __yoF B/P 118/63 HR 85 RR 20 Ox3 2 days post op- JPDrain placement Lungs clear bil, ant/post Hypoactive BS x4 Pt guarding and grimacing, Holding Mom’s hand to sit up. DX: Peritonitis Ruptured appdx.

STUDENT'S NAME ________________________

ANALYSIS

PLANNING

NURSING DIAGNOSIS

CLIENT GOALS/ OUTCOME CRITERIA

Alteration in Comfort/ Pain r/t Disease process, surgical incision, and tissue damage

IMPLEMENTATION NURSING ACTIONS

Patient’s subjective perception of altered comfort/ pain decreases. .

1. Will perform

Aeb STG: 1. Patient’s rating on pain scale within 1 hr of intervention. 2. Diminished or Absent nonverbal indicators (grimace, abd guarding) within 1hr of intervention. LTG: 1. Client will verbalize 2 non-medication ways of pain relief by discharge. 2. Client will ask for medications when she first notices pain increasing, or when she knows she has activity scheduled by discharge.

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baseline assessment at the beginning of ea shift with appropriate pain scale. 2. Reassess client q1-2h.

3. Instruct Pt in methods to splint abd. 4. Explain all procedures

5. Provide Pt with games, books, movies, and phone. 6. Show Pt various positions she may use to reduce pain and discomfort.

SCIENTIFIC PRINCIPLES/ RATIONALE 1. Will help determine the effectiveness of interventions. 2. Will prevent client from suffering from pain for prolonged amt of time. 3. Splinting reduces pain on movement, coughing, and deep breathing. 4. Information helps minimize anxiety, which can exacerbate discomfort. 5. Activities provide distractions from pain. 6. Minimize pressure on bones, joints, muscles and skin.

EVALUATION OBSERVATIONS/ CONCLUSIONS Patient started off day sleeping in til 10am and not wanting to get OOB. Pain 3 (0-5). 30 mins after receiving Ibuprofen 600mg pt was much more cooperative and relaxed. Reported Pain of 1 (0-5). We talked about the importance of positioning, splinting, keeping busy, and also the medication options she had available. Pt verbalized 2 nonmedication relief measures to me. She took a nap after lunch and reported her pain increasing to a 2(0-5). Discussed asking for medication when she needs it or before she knows she has an activity coming up, or will be sleeping for any length of time. Also talked about indicators that her pain meds were wearing off , or her pain level was

Alteration in Comfort/ Pain

beginning to increase. Her Pain level decreased to a 0(0-5) after receiving 325mg of Acetaminophen. STG met and continuing. LTG: Partially met and continuing. Needs revision concerning bathing care of JPDrain related to comfort.

r/t Disease process, surgical incision, and tissue damage

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