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Assessment Objective: ‡Moaning ‡Facial Grimace ‡Vital Signs: RR: 30 bpm PR: 113 bpm

Diagnosis Acute pain related to post surgical incision




Evaluation Goal met Client reported that he could control his pain after 8 hours of intervention Goal met Client verbalize 4/10 pain scale from 8/10 after 30 minutes

Long term:
After 8 hours of intervention client will be able to report that pain is relieved/ controlled.

Obtain client s assessment of pain

Pain is a subjective experience and must be described by the client in order to plan effective treatment To gain trust from the patient for better assessment. Obtain baseline data and to rule out worsening of underlying condition/ development of complications

Establish rapport with the patient

Short term:
After 30 minutes of intervention client will be able to reduce his level of pain.

Vital signs monitored and documented

Provide comfort measures such as touch, repositioning and provide quiet environment

To promote nonpharmacological pain management.

Encourage use of relaxation techniques such as focused breathing, imaging etc.

To distract attention and reduce tension

Promote adequate rest and sleep to facilitate pain relief

To maintain healthy habit of the patient

Reduce or eliminate factors that precipitate or increase pain experience (e.g., fear, fatigue, monotony, and lack of knowledge).

Patients may experience an exaggeration in pain or a decreased ability to tolerate painful stimuli if environmental, intrapersonal, or intrapsychic factors are further stressing them. Prompt responses to complaints may result in decreased anxiety in the patient. Demonstrated concern for patient s welfare and comfort fosters the development of a trusting relationship. To reduce concern of the unknown and associated muscle tension

Respond immediately to complaint of pain.

Review procedures/ expectations and tell client when treatment causes pain

Evaluate the effectiveness of the pain control measures used through ongoing assessment

Research shows that the most common unrelieved pain is failure to routinely assess pain and pain relief. Many client s silently tolerate pain if not specifically asked about it

Dependent: Provide PRN pain medications as ordered

To notify physician if regimen is inadequate to meet pain control goal.