S U NP Comments

ASSESSMENT
1 Identified patient using two identfiers.
2 Assessed patient's risk for pain
3 Asked patient if he or she is in pain, used appropriate
language for patient's values, obtained an interpreter
if necessary
4

Performed hand hygiene. Examined site of patient's pain,

inspected ROM of joints involved, prescussed and
auscultated to help identify abnormalities, determined
cause of pain, auscultated abdomen before palpation
5 Assessed physical, behavioral, and emotional signs and
sysom of pain
6
Assessed characteristics of pain, followed agency policy
regarding frequency of assessment, used PQRSTU pain
assessment.
7 Assessed patient's medical history for succesful pai relief
therapies
8
Assessed patient's response to previous pharmacological
interventions, determined if analgesic side effects are
likely.
9 Assessed for allergies to medications

PLANNING
1 Identified expectd outcomes

IMPLEMENTATION
1
Performed hand hygiene, applied clean gloves if indicated
2 Prepared patient's environment with proper temperature,
lighting, and sounds to allow rest
3 Taught patient how to use pain-rating scale
4 Set pain intensity goal when patient when able
5 Administered pain-relieving medications per health care
provider's order
6
Removed or reduced painfull stimuli by assisting patient
to comfortable osition and repositining linens, bandages,
tubes, and equipment as needed.
7
Taught patient how splint ver painful sight using pillow or
hand:
a. Explained urpose of splinting
b. Placed pillow or blanket over site, asssisted patient to
place hands firmly over area of discomfort
 c. Had patient hold area firmly while coughing, deep
breathing and turning.
8 Reduced or eliminated emotional factors that increase
pain experiences:
a. Offered information that reduces anxiety
b. Offered patient oportunity to pray
c. Spent time to allow patient to talk about pain
9 If used , removed and disposed of gloves, perfom hand
hygiene
Evaluation
Asked patient to describe level of relief within 1 hour of
intervention
1
2 Compared patient's current pain with personally set pain-
intensity goal
Compared patient's ability to function and perform ADLs
before and after pain intervetions
3
4 Observe paatient's nonverbal behaviors
5 Evaluated for analgesic side effects
6 Identified unexpected outcomes