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Pain Care Plan

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Nursing Role in Pain, Sleep, or Comfort Management


    Mr. Campos is a 57-year-old man who was admitted to the surgical unit for treatment of a possible strangulated inguinal hernia. Two days ago he had a partial bowel resection. Postoperative orders include NPO, intravenous infusion of D51/2 NS at 125 cc/hr
left arm, nasogastric tube to low intermittent suction. Mr. Campos is in a dorsal recumbent (supine) position and is attempting to draw up his legs. He appears restless and is complaining of abdominal pain (7 on a scale of 0–10). VS T 98.6° P 90 R 24 BP 158/82, Skin pale and moist, pupils dilated. Midline abdominal incision, sutures dry and intact.

      Desired outcomes consist of: Pain Control as evidenced by often demonstrating ability to use analgesics appropriately, use nonanalgesic relief measures, and report uncontrolled symptoms to health care professional. Pain Level as evidenced by mild to no reported pain, protective body positioning, restlessness, pupil dilation, perspiration, change in BP, HR, R from normal baseline data.
     
    Upon assessment: acute pain related to tissue injury secondary to surgical intervention, evidence by   restlessness, pallor, elevated pulse, respirations, and systolic blood pressure; dilated pupils, and a report of 7/10 pain. Impaired comfort related to surgery, secondary to IV lines, nasogastric tube, and positioning, evidence by patient trying to draw up his legs.   Sleep deprivation, related to pain secondary to surgery, evidence by restlessness. Risk for infection, related to surgery, secondary to IV line.

    I plan to perform a comprehensive assessment of pain to include location, characteristics, onset, duration, frequency, quality, intensity or severity, and precipitating factors of pain. Pain is a subjective experience and must be described by the client in order to plan effective treatment. I will provide Mr. Campos optimal pain relief with prescribed analgesics. Each client has a right to...

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