NURSING PROCESS CARE PLAN

Alteration in Comfort/ Pain

PATIENT'S INITIALS: ________________ STUDENT'S NAME ________________________

DATES OF CARE: ___________________

ASSESSMENT ANALYSIS PLANNING IMPLEMENTATION EVALUATION

SUPPORTIVE CLIENT GOALS/ SCIENTIFIC

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.
NURSING
DIAGNOSIS
Alteration in Comfort/ Pain
r/t
Disease process, surgical
incision, and tissue damage
OUTCOME NURSING PRINCIPLES/ OBSERVATIONS/
CRITERIA ACTIONS RATIONALE CONCLUSIONS
Patient’s subjective 1. Will perform 1. Will help determine Patient started off day
perception of altered baseline assessment the effectiveness of sleeping in til 10am and
comfort/ pain at the beginning of interventions. not wanting to get OOB.
decreases. . ea shift with Pain 3 (0-5). 30 mins after
appropriate pain receiving Ibuprofen 600mg
2. Will prevent client
Aeb scale. pt was much more
from suffering from
2. Reassess client q1-2h. cooperative and relaxed.
pain for prolonged amt
STG:
of time. Reported Pain of 1 (0-5).
1. Patient’s rating on
pain scale within 1 hr of 3. Splinting reduces We talked about the
intervention. 3. Instruct Pt in methods pain on movement, importance of positioning,
2. Diminished or Absent to splint abd. coughing, and deep splinting, keeping busy,
nonverbal indicators breathing. and also the medication
(grimace, abd guarding) 4. Information helps options she had available.
within 1hr of 4. Explain all procedures minimize anxiety, Pt verbalized 2 non-
intervention. which can exacerbate medication relief measures
discomfort. to me.
LTG: 5. Activities provide She took a nap after lunch
1. Client will verbalize 2 5. Provide Pt with games, distractions from pain. and reported her pain
non-medication ways of books, movies, and increasing to a 2(0-5).
pain relief by discharge. phone.
2. Client will ask for 6. Minimize pressure Discussed asking for
6. Show Pt various medication when she needs
medications when she positions she may use to on bones, joints,
first notices pain muscles and skin. it or before she knows she
reduce pain and has an activity coming up,
increasing, or when she discomfort.
knows she has activity or will be sleeping for any
scheduled by discharge. length of time.
Also talked about
indicators that her pain
meds were wearing off , or
her pain level was

1
Alteration in Comfort/ Pain
r/t
Disease process, surgical
incision, and tissue damage
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.