Pain 2/10 at rest, controlled on the scheduled regimen, no effect on participation/sleep; PAINAD 1 as the resident has advanced dementia — adequate control against the ordered plan; supports Section J and the comfort goal.
Post-op pain controlled
Scheduled analgesic with breakthrough available, pain 3/10 with movement (down from 6/10), participating in therapy, sleeping through the night; opioid with bowel regimen, no oversedation, RR 16 — effective monitored control; supports Section J/N.
PRN response with reassessment
Pain 6/10 → PRN analgesic per order → reassessed 30 min: 2/10, resumed activity — effect and timing documented; skilled reassessment; supports Section J.
