Three worked care plans

C1 Short-term pain (actual problem)

Mr. Hassan, 58, day 1 after open appendectomy.

Assessment: S: "It hurts when I cough or move." O: pain 7/10 at the incision; grimacing; guarding the abdomen; pulse 104/min; blood pressure 138/84; reluctant to turn.

Assessment tools for this scenario: CP-PAIN Pain & Comfort Score · CP-SKIN Skin & Wound Score · CP-BREATH Breathing & Circulation Check

Validated scales to consider: NRS 0–10, FLACC, PAINAD, Braden Scale, TIME wound chart, NEWS2, SpO₂, ECG

Diagnosis: Short-term pain related to a surgical incision, as evidenced by a pain score of 7/10, guarding, and a pulse of 104/min.
Goal: Pain 3/10 or lower within 1 hour of pain relief; turns in bed without grimacing by the end of the shift.

Intervention	Rationale
Assess pain with the same scale each time, including location and what makes it worse	A consistent score shows whether the plan is working
Give pain relief on time as ordered, before moving or coughing exercises	Treating early keeps pain from building and lets him move
Teach him to splint the incision with a pillow when coughing	Reduces pull on the wound and pain
Reposition and offer cold or heat only if ordered	Comfort measures add to, not replace, medicine
Re-check pain, sedation, and breathing 30 to 60 minutes after each dose	Confirms relief and catches side effects early

Evaluation: At 1 hour pain was 3/10; he turned himself without grimacing. Goal met.

Mrs. Nasser, 81, admitted with a chest infection.

Assessment: S: "I get up at night to use the bathroom and I am a bit wobbly." O: fell last year; unsteady gait; takes a sleeping tablet; high fall-risk score; wears loose slippers; no fall in hospital so far.

Assessment tools for this scenario: CP-SAFE Safety & Falls Score

Validated scales to consider: Morse Fall Scale

Diagnosis: Likely to fall related to weakness, a sleeping tablet, and a past fall (risk factors); no fall has occurred.
Goal: No falls during the stay; calls for help before getting up; names three fall-prevention steps by discharge.

Intervention	Rationale
Keep the bed low, brakes on, and the call bell in reach	Reduces injury and makes help easy to reach
Offer the toilet before the sleeping tablet and at set night times	Stops hurried, unassisted night trips
Provide non-slip footwear; clear the path and light the way	Removes common hazards
Assist with walking and use a walking aid if prescribed	Matches support to her real ability
Ask the doctor or pharmacist to review the sleeping tablet	Sedatives raise fall risk, especially in older adults

Evaluation: No fall by day 6; she called for help each time and named three steps at discharge. Goal met.

Ms. Rahim, 44, with insulin-treated diabetes; lunch is late.

Assessment: S: "I took my insulin but lunch has not come yet." O: blood sugar 5.2 mmol/L before lunch; insulin given 30 minutes ago; recent infection; no sweating or shaking.

Assessment tools for this scenario: CP-FLUID Fluid Balance & Nutrition Score · CP-INFECT Infection Check

Validated scales to consider: MUST, fluid chart, glucose, qSOFA / sepsis screen

Diagnosis: Unsteady blood sugar related to insulin, a delayed meal, and infection (risk factors); no signs of the problem are present yet.
Goal: Blood sugar at or above 4 mmol/L through the stay; states the warning signs of low sugar and what to do before discharge.

Intervention	Rationale
Call the kitchen and give a safe snack now	Fast-acting insulin without food can drop sugar quickly
Recheck blood sugar before the meal and if symptoms appear	Early checks catch a fall before symptoms
If sugar is below 4 mmol/L: treat at once per protocol and recheck in 15 minutes	Low sugar is an emergency and the treatment is time-critical
Teach warning signs: shaking, sweating, hunger, confusion	Lets her act before an emergency develops

Evaluation: She ate 20 minutes later, sugar 6.8 mmol/L; no symptoms. Goal met.