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PLANNING/IMPLEMENTING/EVALUATION (See Grading Rubric for NCP
Criteria) Nursing Diagnosis: impaired comfort R/T increased abdominal

pain AEB increased use of pain medicine and tenderness with palpation
Long Term Goal: Patient will remain comfortable
Outcome Criteria
Interventions
Rationale
Evaluation
One outcome criteria for

each intervention. Number
each one.
Label each intervention as:

Assess/Monitor/Independent/
Dependent/Teaching/Collaboration
Answers why, how, what your intervention will help solve,

prevent or lessen the stated problem specific to this
patient.
Evaluate the patient

outcome; NOT the
intervention.
1. Patients VS
will remain
between the
following as
assessed
Q4H and
prn:
T: 97.8-99.1
P: 60-100
R: 12-20
SBP: 90-160
DBP: 50-90
O2: >92% ra
1. Assess VS Q 4 H and
PRN
Independent
1. My patient is an 81 year old

female who presented to the ER
with abdominal pain and was
diagnosed with diverticulitis with
a perforated abscess. It was said
that the best treatment for her
was to make her comfortable at
this time due to the extent of the
infection in the abdomen. It
becomes very important to
watch for physiologic changes
such as rapid, shallow
respirations, increased pulse
rate, and elevated blood
pressure. An increase in these
may indicate an increase in the
1. This goal
was met and
is ongoing.
It is ongoing
since we
always want
the VS within
these
parameters.
Since her BP,
AP, and resp.
were WNL
we can infer,
based on her
behavior as
well, that her
pain is being
controlled.
pain level. Acute pain is known

to lead to generalized arousal
and an increase in sympathetic
nerve activity. This occurs by
pain stimulating the SNS which
then increases the heart rate
and vasoconstriction leading to
the elevation in BP. These
become important for this
patient since she had a Dx of
dementia and may have a hard
time expressing her pain level
accurately. We are also
watching her VS for a side effect
of her pain medication,
Morphine, which is known to
decrease resp., by depressing
the CNS which can then
decrease the O2 saturation.
We can also
see that she
is not
experiencing
any adverse
effects from
the pain
meds, such
as a
depression of
the CNS.
2. Patients pain
level will
trend down
from 8/10 to
0/10 within
20 minutes
of
administratio
n
2. Morphine 4 mg IV Q 1
prn
Dependent

infection in the abdomen.
Morphine is an opioid analgesics
that is used to treat moderate to
severe pain. This drug binds to
opiate receptors in the CNS and
produces a generalized
depression of the CNS. At this
time the medical team thought it
best to treat her for the infection
via IV therapy but did not expect
this to have a great effect. So it
was said that keeping her
comfortable was the main goal.
This was one of the drugs of
choice since it has a rapid onset
and the patient should begin to
feel the effect rapidly and will
2. This goal was

partially met and is
ongoing since we
want to keep her
free from pain. At
one point in the
morning she had
complained of an
8/10 ABD pain and
a recheck in 20
minutes produced
a pain level of 2/10.
This was much
improved but not
at our goal. This is
when the PA was
talking to patient
and ordered a
onetime dose to be
given now to get to
the goal of 0/10.
3. Patient will
state a pain
level of 0/10
within 3
minutes of
administratio
n
3. Fentanyl 25mcg IV
Q1H prn
Dependent
peak in 20 minutes.

Fentanyl is an opioid analgesic
that is often used to treat
moderate to severe pain. It
works by binding to the opiate
receptors in the CNS altering the
response to pain. This is a rapid
working drug and the patient
should feel the effects in 1-2
minutes and peak in five
minutes. This drug would be
used as a breakthrough
medicine for in between doses of
a longer acting drugs, with the
goal to keep the patient free
3. This goal was not

met and is ongoing.
It was not met
since it was not
given. The PA
discussed this with
the primary nurse
and myself and
decided to give a
onetime dose of
Morphine so that
this order would be
available to use if
the Morphine was
ineffective. But the
patient did not
need to use this
med.
4. Zofran 4 mg IV Q4H
prn
from pain at all times.
4. Patient will
state nausea
is 0/10
within 10
minutes of
Zofran
administratio
n

The drug Zoran is an antiemetic
and was ordered for her to prevent
or reduce nausea due to the
infection in her abdomen. This
drug blocks the effects of serotonin
at the receptor sites located in the
vagal nerve terminals and the
chemoreceptor trigger zone in the
CNS. My patient is experiencing
one of the classic symptoms of
diverticulitis, nausea. This drug
was given to reduce this feeling and
help to make the patient
4. This goal was

ongoing. The
patient complained
of extreme nausea
10/10. She had
then received the
Zofran and a
recheck in 10
produced a positive
result. The patient
was not responding
to me with a
number as she did
before. But she did
produce a smile
and stated, still
there but oh much
better. She no
longer was
guarding her ABD
or showed facial
grimacing.
5. Zosyn IVPB 3.37g @

12.5ml/h Q 8h
Dependent
5. Patient
states
improvemen
t in
abdominal
pain by third
day of ABX
treatment
comfortable. She should start feel

the drugs effects within 10 minutes
of administration.

Although the team felt it best to
keep her comfortable, they are
still treating the infection with
this ABX. By treating the
infection, we will be eliminating
some of the side effects that are
causing her discomfort, nausea,
distention, and tenderness with
light palpation. If some of the
inflammation in the abdomen
5. This goal is not

met and is ongoing.
Although the ABX
Zosyn appears to
be having a
positive effect since
her WBC are
trending down from
38.7-29.1. But she
is still experiencing
pain in her ABD
which is known
based on her
responses and her
usage of pain meds
and Zofran.
6. Assess LLQ drain Q S

and prn
Independent
6. LLQ drain
will remain
free from
infection as
assessed QS
and prn
subsides then so does the

distention and much of the
pressure and tenderness that
she is experiencing. The ABX
Zosyn is an anti-infective that is
often given for infections r/t the
abdomen, such as peritonitis,
which is an infection to the
perineum. This drug works by
binding to bacterial cell wall
membranes and then causes the
cells death.

infection in the abdomen. To
help provide her with this
comfort she had a drain placed
in her LLQ to assist with draining
some of the fluid out of her
abdomen where she had he
6. This goal is met

and is ongoing.
This goal was met
since every time
the drain was
assessed it was
free from infection
and irritation.
There was no
redness of the
surrounding tissue,
no drainage was
noted and was not
warm to the touch.
There was a drain
sponge in place
and that as well
was free from
drainage. Although
7. Assess abdomen Q
4H and prn
Independent
7. Abdomen
will be
positive for
BS X4 Q,
non-tender,
and trending
toward nondistended
as assessed
QS and prn
abscess. It becomes very

important to watch the drain for
this patient since she has
periods of confusion and is
known to pull on it. She is then
introducing the bacteria from
her hands onto the drain that is
directly entering her already
infected abdomen putting her at
a greater risk even more
infections to occur. She could
also develop a cutaneous
infection of the surrounding
tissue that would offer her even
more discomfort, which we are
trying to avoid. And we want to
be able to keep the drain in
place to attempt to drain out the
fluid from her abscess resolving
some of the tenderness.
7. My patient is an 81 year old female
who presented to the ER with
abdominal pain and was diagnosed
with diverticulitis with a perforated
abscess. It was said that the best
treatment for her was to make her
comfortable at this time due to the
extent of the infection in the
abdomen. It is important to do a
this goal was met,

it needs to continue
to be ongoing as
long as the drain is
in place.
7. This goal is
unmet and is
ongoing.
Her ABD
assessment
produced the
following
results: BS
X4Q, very
diminished
and
hypoactive,
tender to
touch and
movement,
8. Reposition Q2H and

prn
Independent
8. Patient will
state an
8/10 level of
comfort
following
repositioning
Q2H
thorough physical abdominal exam to

know what is going on with the
patient. It will be important to know if
the patient has bowel sounds and that
they are actively working prior to the
taking in any food po. Since a
common side effect of diverticulitis
with an abscess are hypoactive or
absent BS it becomes important to
know if the patient is experiencing this
so the medical team knows how the
current treatments are working. You
will want to visualize the abdomen Q S
to know if the distention is trending
down, since this will help to eliminate
much of the pain and tenderness she
is experiencing. The results we
receive from this exam will help us to
know how many of our other
interventions are working as well. If
she continues to have pain with
palpitation then we know the
inflammation is still present.
8.My patient is an 81 year old female

and
distended.
Although I
had not seen
this patient
days prior to,
the staff and
family
informed me
that her ABD
distention
has
improved
greatly.
8. This goal was

met and is ongoing.
Although I patient
was not always
sable to give a
number the
assessment of the
patient can be
used. Including the
FLACC scale. The
9. Provide rest periods

between activities
and prn
Independent
9. Patient will
not display
SOB,
increased
respirations,
or an
increased
pain level
during
activities

abdomen. It becomes critical to
reposition this patient Q 2 hours due
to her current NPO status and recent
decrease in po intake as well as her
age of 81 years. Since all these put
her at a greater risk for skin
breakdown. The skin of the elderly
has a flattening of the epidermaldermal junction which weakens the
skin. The elderly often have a
decrease in subcutaneous fat as well,
putting their risk even higher for skin
breakdown. Since the skin is thinner
and glands (sweat and oil) are now
less active the skin is dry and more
susceptible to breakdown of pressure
areas of the skin. This on top of the
fact that she is not ambulatory and
needs assistance to be repositioned.
And since she has been NPO for a
week she does not have the needed
nutrition to keep adequately healthy
skin. As for moving, it may be
uncomfortable for her, so she is prone
to stay in the same position for as long
as we allow, thus increasing pressure
and setting up the stage for a pressure
patient would state

if she was not
comfortable
following
repositioning, even
though she was
unable to
communicate an
exact number.
Given the amount
of distention in her
ABD we would
expect some form
of discomfort with
moving and
changing positions,
although we want
to make sure there
is no pain.
9. This goal is met

and ongoing. At no
point during the
day did my patient
become SOB or
experience
10.
D5 1/2 NS
with 20 meq KCL @
100 ml/hr
Dependent
10.
Patient
will not have
increased
pain to the
abdomen as
assessed
while in the
hospital
ulcer to form. This in turn would cause

more pain and discomfort.
9.My patient is an 81 year old female
abdomen. Since our ultimate goal is
to keep this patient comfortable we do
not want her to experience increased
respirations or pain while performing
activities. An increase in these can
also lead to an increase in anxiety.
You want to be sure to let the patient
rest at a point before any of the signs
or symptoms are noticed. If we begin
to see any change in respirations we
need to stop, even if the patient states
they are fine. We must stop the
problem from occurring by resting
before a problem ensues. And we
must remember that pain and
discomfort are subjective, so even if
the patient does not appear to be in
pain but she states it, we go with what
is stated by the patient. And if the
patient is unable to verbalize on a pain
increased
respiration. And
although she did
have pain it was
exacerbated by her
activities. She was
able to rest in
between her
activities. Her
activities included
OOB to chair and
commode.
11.
Provide back
rub QS and prn
Independent
11.
Patient
will state an
8/10 level of
comfort
following
back rub
scale of 1-10, we would use the FLACC

scale to obtain a pain level. This scale
is used to judge pain in patients that
are unable to communicate a pain
level by assessing them. They will be
judged on arms, legs and activity
level. As well as vocalization and
ability to be consoled.
10. My patient is an 81 year old female

abdomen. If we want to keep this
patient comfortable then we need to
rest her bowels, since this is where the
infection is, and we do this by placing
her on an NPO diet which means she
can have nothing by mouth, except
her medications. We do this to give
the bowels a chance to heal without
having to do their usual activity since
this would cause an increase in pain to
the patient. Since she can eat nothing
she is receiving the D51/2 NS to keep
10. This goal was

unmet and is
ongoing. Although
she is being
medicated for her
pain and it is
uncontrolled, her
pain has not
subsided without
the intervention of
medicine. We want
to rest the bowels
so that they can
heal and the
inflammation will
be decreased
causing a reduction
in pain. But this
has not occurred
yet. She is still
experiencing
abdominal pain. At
one point it was
8/10 and following
med admin it was
2/10.
12.
Teach
relaxation
techniques BID and
prn
Independent
her glucose levels from dropping. It is

also infused with Potassium to keep
her electrolytes in balance.
12.
Patient
will
demonstrate
proper
relaxation
breathing
during rest
periods

infection in the abdomen. Not
only does the back massage
help to relieve back pain due to
her decreased mobility, but it
helps to relax all the muscles
and that in turns helps the other
interventions and medications
for pain work more efficiently. It
is also known that physical touch
can be calming. Just knowing
that there is someone there is
even calming to some patients.
11. This goal was

met and is ongoing.
This goal was met
based on that when
the patient was
uncomfortable she
stated so. And
following the back
rub she stated she
was fine. She had
no facial grimacing
and stated that
feels good at one
point during the
back rub.
13.
Provide mouth
care Q4H and prn
Independent
13.
Patient
will maintain
moist mucus
membranes
as assessed
Q 4H and
prn

infection in the abdomen. It
becomes important to teach her
and her family relaxation
breathing techniques so that she
can do this on her own or with
the help of her daughters. This
then becomes something that
incorporates her daughters into
her care which is often what
families and patients want.
Relaxation not only decreases
12. This goal was

ongoing. The
patient was able to
take slow breaths
and was instructed
to concentrate on
taking them. But
the patient does
not have the
cognition level do
remember to do
this breathing
without instruction.
This would be an
intervention to with
patient whenever
in the room for any
reason to promote
comfort and
relaxation.
14.
Collaborate
with a representative
from Francis House
prior to d/c and
placement
14.
Patient
will qualify
for
placement at
Francis
House prior
to d/c
the actual pain level but may

aide is sleep, give energy,
reduce anxiety, and increase
effect of pain medicine. You
want to instruct the patient to
take slow deep (but not too
deep) breaths at the rate of 12
per minute while eyes are closed
and are only concentrating on
breathing. This may be difficulty
due to the cognitive impairment,
but the slow breathing itself is
relaxing and will take her mind
off of the pain in the abdomen
which is the goal.

infection in the abdomen. Mouth
care becomes very important to
the elderly, especially when they
have a Dx such as dementia
such as this patient. Not only
does it become a memory
13. This goal is met

and is ongoing.
This goal was met
since I provided
mouth care with
every interaction.
She stated her
mouth had no pain
and per
assessment MM
were moist and
pink. Often times
it is the basic care
that gets neglected
since it is not
pertinent to the
problem. But
having a clean,
moist mouth will
help to improve the
patients overall
feeling.
15.
Provide a
quite environment
for two hours BID
while awake
15.
Patient will
state she
feels rested
and relaxed
following
rest period
concern but a physiologic

concern as well. Many older
adults suffer from xerostomia, or
dry mouth. Being that my
patient is NPO she needs mouth
care often to promote comfort.
Being nauseas and having no
interest in food has decreased
the saliva production and will
increase dryness of the oral MM.
The nurse is able to not only
clean her mouth with a moist
toothette but moisten it, and
help to stimulate the production
of saliva which is minimal at this
point.

infection in the abdomen. It is
important for the representative
from Francis House to speak with
14. This goal is

partially Met and is
ongoing. This goal
was only partially
met since the rep
was at the hospital
and spoke with the
nurse but no final
decisions were
made. This will
take some time and
would not be
known today. This
intervention would
end if placement
somewhere else
was found.
the nurse in order to acquire the

necessary information. The
patient needs to be a DNR and
have less than 6 months to live
to qualify for the Francis House.
Since the Rep is unable to get
into the computer system, they
need to talk to staff that knows
about the case. There is an
entire packet that the Rep must
fill out, but some of the pertinent
information is: code status, life
expectancy, current condition
15. This goal is Met
and Dx, and many financial
and is ongoing. My
factors as well. A great deal is
patient was up in
needed to be known since
her chair for the
Francis House offers beds to
morning and then
those in the greatest need at
went back to bed in
that time and not from when the the afternoon. Her
referral was made.
door was half shut

and her room was

darkened and
quiet. When I went
in after sometime
she stated the rest
did her good.
Although she did
not sleep she was
able to rest and
that along felt good
to her.
infection in the abdomen. Rest

becomes difficult to obtain when
one is in pain. It becomes
important to eliminate
environmental stimuli as much
as possible when patient is
resting to promote adequate
rest. It is proven that a patient
finds it easier to relax in a calm,
quiet environment. Oftentimes
noise and activities of others will
increase anxiety and prevent
relaxation, and we must
remember that noises
experienced in a hospital are not
the average everyday noises.
Sometimes these stimuli may
even cause sleep deprivation.
This is when rest periods are
often helpful throughout the day.
Outcome Criteria
Interventions
Rationale
Evaluation

each one.


patient.

outcome; NOT the
intervention.
Outcome Criteria
Interventions
Rationale
Evaluation

each one.

Outcome Criteria
Interventions
Answers why, how, what your

intervention will help solve, prevent or
lessen the stated problem specific to
this patient.
Rationale

outcome; NOT the
intervention.
Evaluation

each one.

Answers why, how, what your intervention will help solve, prevent
or lessen the stated problem specific to this patient.

outcome; NOT the
intervention.
Outcome Criteria
Interventions
Rationale
Evaluation

each one.


outcome; NOT the
intervention.
Outcome Criteria
Interventions
Rationale
Evaluation

each one.


outcome; NOT the
intervention.
Outcome Criteria
Interventions
Rationale
Evaluation

each one.

PLANNING/IMPLEMENTING/EVALUATION (See Grading Rubric for NCP

Criteria) Nursing Diagnosis

outcome; NOT the
intervention.
Long Term Goal
Outcome Criteria
Interventions
Rationale
Evaluation

each one.


patient.

outcome; NOT the
intervention.
Outcome Criteria
Interventions
Rationale
Evaluation

each one.


patient.

outcome; NOT the
intervention.
Outcome Criteria
Interventions
Rationale
Evaluation

each one.

Outcome Criteria
Interventions
Answers why, how, what your

intervention will help solve, prevent or
lessen the stated problem specific to
this patient.
Rationale

outcome; NOT the
intervention.
Evaluation

each one.


outcome; NOT the
intervention.
Outcome Criteria
Interventions
Rationale
Evaluation

each one.


outcome; NOT the
intervention.
Outcome Criteria
Interventions
Rationale
Evaluation

each one.


outcome; NOT the
intervention.
Outcome Criteria
Interventions
Rationale
Evaluation

each one.


outcome; NOT the
intervention.

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PLANNING/IMPLEMENTING/EVALUATION (See Grading Rubric for NCP

Criteria) Nursing Diagnosis: impaired comfort R/T increased abdominal

Long Term Goal: Patient will remain comfortable

One outcome criteria for

Label each intervention as:

Answers why, how, what your intervention will help solve,

Evaluate the patient

1. My patient is an 81 year old

pain level. Acute pain is known

2. My patient is an 81 year old

2. This goal was

3. My patient is an 81 year old

3. This goal was not

from pain at all times.

female who presented to the ER

4. This goal was

5. Zosyn IVPB 3.37g @

comfortable. She should start feel

5. My patient is an 81 year old

female who presented to the ER

5. This goal is not

6. Assess LLQ drain Q S

subsides then so does the

6. My patient is an 81 year old

female who presented to the ER

6. This goal is met

abscess. It becomes very

this goal was met,

8. Reposition Q2H and

thorough physical abdominal exam to

8.My patient is an 81 year old female

8. This goal was

9. Provide rest periods

treatment for her was to make her

patient would state

9. This goal is met

ulcer to form. This in turn would cause

scale of 1-10, we would use the FLACC

10. My patient is an 81 year old female

10. This goal was

her glucose levels from dropping. It is

11. My patient is an 81 year old

female who presented to the ER

11. This goal was

12. My patient is an 81 year old

female who presented to the ER

12. This goal was

the actual pain level but may

female who presented to the ER

13. This goal is met

concern but a physiologic

14. My patient is an 81 year old

female who presented to the ER

14. This goal is

the nurse in order to acquire the

15. My patient is an 81 year old

female who presented to the ER