Questions about my careplan and process paper PLEASE!

[miavrl]

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!!

[1234student]

I'm not familar with a "process paper" but if you were assessing pain and there was no way for you to assess areas of pain, then i would just leave it out. How did you get the face grimace? Like when you touched the leg they made a face???

[miavrl]

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

[1234student]

Then i would just say that. Pt unble to verbilize, grimaced and moaned when turned indicating pain. I know at my hospital that have a special section to assess pain with if they are nonverbal.