Alteration in Comfort: Pain
Published on Monday October 12th , 2009
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
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