Alteration in Comfort: Pain

Alteration
in Comfort: Pain

(_)Actual (_)
Potential

Related
To:
[Check
those that apply]
(_)
Musculoskeletal disorder
(_) Visceral disorder
(_) Cancer

(_) Information
(_) Trauma
(_) Diagnostic test

(_)
Immobility/improper positioning
(_) Pressure points

(_) Pregnancy
(_) Fear
(_) Anxiety/stress
(_) Overactivity
(_) Other:_____________________________
____________________________________

____________________________________

 

As
evidenced by:
[Check
those that apply]
Major:

(
Must be
present
)
(_) Pt. reports or
demonstrates discomfort.
Minor:

(
May be
present
)
(_) Autonomic
response to acute pain:
  • increased BP, P,
    R
  • diaphoresis
  • dilated pupils
  • guarding
  • facial mask of
    pain
  • crying/moaning
  • abdominal
    heaviness
  • cutaneous
    irritation

 

Date &

Sign.

Plan and Outcome
[Check
those that apply]
Target
Date:
Nursing Interventions
[Check
those that apply]
Date
Achieved:
  The
patient will:

(_)
Experience relief of pain A.E.B.

  • verbal reports of
    relief of pain
  • less autonomic
    responses to pain

(_) Other:

  (_)
Asses characteristics of pain: location, severity on a
scale of 1-10, type, frequency, precipitating factors,
relief factors.

(_)
Eliminate factors that precipitate pain:
eg.:__________________
________________________

(_) Offer analgesics
q___ hrs prn (according to physician order).

(_) Teach patient to
request analgesics before pain becomes severe.

(_) Explore
non-pharmacological methods for reducing pain/promoting
comfort:

  • back rubs
  • slow rhythmic
    breathing
  • repositioning
  • diversional
    activities such as music, TV, etc.

(_)
Other:________________

________________________
________________________
________________________

 

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature