Full Answer Section

Patient Information:

• Name:
• Date of Surgery:
• Expected Discharge Date:

Section 1: Pain Management Expectations

Overall Comfort Level:

Please indicate your desired level of comfort on a scale of 1 (least comfortable) to 10 (most comfortable):

• _____ (1) _____ (2) _____ (3) _____ (4) _____ (5) _____ (6) _____ (7) _____ (8) _____ (9) _____ (10)

Acceptable Pain Levels During Activities:

• Resting: _____ out of 10
• Walking: _____ out of 10
• Deep Breathing Exercises: _____ out of 10
• Coughing/Sneezing: _____ out of 10

Section 2: Chronic Discomforts and Home Management Strategies

Do you experience any chronic discomforts? (e.g., back pain, headaches)

• Yes * No (If no, skip to Section 3)

If yes, please list your chronic discomforts and the interventions you use at home for relief:

• Discomfort 1: _____
  • Home Management Strategies: _____
• Discomfort 2: _____
  • Home Management Strategies: _____

Section 3: Communication Preferences

• How would you like to be notified about pain medication options? (circle all that apply)
  • Verbally by nurse
  • Written information sheet
  • Both
• Please indicate your preferred pain medication delivery method (circle all that apply):
  • Oral medication
  • Intravenous (IV) medication
  • Patient-controlled analgesia (PCA) pump (if applicable)
• Do you have any concerns or questions about pain management after surgery?

Section 4: Agreement

We, the undersigned, have discussed the contents of this Comfort Contract and agree to work together to achieve the patient’s desired level of comfort after surgery.

• Patient/Surrogate Signature: ____________________ Date: ____________
• Nurse Signature: ____________________ Date: ____________

Benefits:

• Patient-centered care:Empowers patients to communicate their expectations and preferences.
• Improved pain management:Tailored pain relief plans based on individual needs and tolerance.
• Reduced anxiety:Clear communication about pain management options can alleviate anxiety.
• Enhanced communication:Facilitates ongoing communication between patients and nurses.

Please note: This is a sample contract and might need to be adapted based on the specific hospital policies and patient needs.