Impaired Comfort r/t TKR Assessment Abnormal Findings Objective Data: pain level 8 on numerical scale 0 (least) -10

(worst) Nursing Diagnosis (actual or risk for) Subjective Data: Patient reports pain in left leg.

Formulate Diagnosis

Nursing Diagnosis formed from NANDA Impaired Comfort r/t TKR, AEB category R/T S/O data grimacing, verbalizing discomfort. Plan Goal: The pt. will The patient will experience a satisfactory relief measure Outcomes: As evidenced by - Increased participation in activities for recovery. - Reduction in pain behaviors (grimacing, guarding affected area) Interventions:
Discuss the use of cold applications, their therabeutic effects, indications, and related precautions. - Ice Bag

Goal from patients viewpoint. Indicate measurable outcomes and include time frame.

Interventions
Begin with action verb; indicate type, frequency, amount where appropriate; State scientific rationale/ psychological principle for each intervention.

Rationale
Purpose is to decrease pain, muscle spasms, and inflamation. Lowers temperature of the skin and underlying tissue, Causes vasoconstriction, reducing bloodflow to the affected area. Produces skin pallor and coolness. Prolonged exposure can damage skin tissue from lack of oxygen and nourishment. Has a local anesthetic effects.

Determine the preferred administration routeby mouth, intramuscular, intravenous, or rectal.

Provide pain relief with prescribed analgesics. Assess vital signs before administration and 30 minutes after.

The proper administration route optimizes the efficacy of pain medications. The oral route is preferred in most cases.
Narcotics can supress the respiratory system. Respirations <8 warrant a hold and check before administering medication or notifying physician.

Kotzen 1

Impaired Comfort r/t TKR Reassess patients pain level 30 minutes after administration. Each patient responds differently to pain medication; careful monitoring is needed to assess individual response.

Evaluation

Goal has been:

Provide evidence: Patient reports pain at a 4. Grimacing has subsided.

Have the goals/outcomes been met? Provide evidence.

Met Partially met Not met

Kotzen 2