miavrl

LUVOFNURSING Can you email it to me >? I cant figure out how to PM you...

yeah whenever we turned the pt they would grimace or moan.

What are your other nanda's? I personally wouldn't use fluid volume deficit.

i am writing a care plan and process paper on a pt. who had surgery on her leg due to a femur fracture. my pt. had a traumatic brain injury years ago and is unable to speak or communicate and is not orientated x 4 and is a quadriplegic. the only way to tell if they had pain was by slight facial grimacing or slight moaning. while writing my process paper i am getting stuck on a certain area:how do i describe the pt.'s pain? for example i usually write something like this: comfort/rest pain: 8/10 (on scale of 1-10). head: throbbing, radiating sensation. duration: one hour. aggregating factors: movement. relieving factors: tylenol (tx: tylenol, 650mg po q6h prn, analgesic, pain relief, side effects: hepatic failure (overdose), rash, urticaria) but for my current pt. i don't have a pain scale since they are unable to communicate with me and i do not have a description of the pain, so what do i do? or how would i word that? it's driving me crazy. i had no family to communicate with either. i have my careplan written out and my nanda's but i just can't get past the process paper in that area!!