ACUTE PAIN - Weebly



ACUTE PAIN

|ASSESSMENT/ |NURSING DIAGNOSIS |BACKGROUND KNOWLEDGE |GOAL/ |NURSING INTERVENTIONS |RATIONALE |EVALUATION |

|CUES | | |OBJECTIVES | | | |

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|Subjective |Alteration in comfort: Acute |Acute pain is an unpleasant |Long Term: |Assessed pain by providing pain |To evaluate the patient’s |Goal unmet. |

| |hypogastric pain related |sensory and emotional |To facilitate the maintenance|rating scale of 0 to 10. |response to pain. | |

|“Sobrang sakit talaga ng tyan |to ineffective tissue |experience arising from actual|of regulatory mechanism and | | |Although the patient has |

|ko,” as vebalized by the patient.|perfusion as manifested by |or potential tissue damage; |functions. |Monitored and recorded V/S. | |identified the different |

| |verbal response of a pain |sudden or slow onset of any | | |To serve as baseline data. |predisposing factors and was |

|Objective |scale of 9/10, 10 being the |intensify from mild to severe |Short term: | | |encouraged to use the |

|Hypogastric pain |highest, body weakness and |with an anticipated end and a |At the end of the shift, the |Discussed with the patient the | |different relaxation |

|Guarding Behavior |facial mask. |duration of less than 6 |patient will report a |different predisposing factors that|To find ways on how to avoid them|techniques taught, the pain |

|Evident body weakness | |months. |decrease in the pain scale |may cause or increase pain such as |or avoid increasing pain being |did not decrease by the end |

|Facial mask | | |from 9 as severe pain to 5 as|stress. |felt. |of the shift for the reason |

|Pain scale of 9/10 | | |moderate pain. | | |that the patient was sent to |

| | | | | | |DR for VSD. |

|Pain scale: | |Pain resulting from uterine | |Encouraged use of relaxation skills| | |

|Severe pain: 8-10 | |cramping is an expected part | |like proper breathing technique, | | |

|Moderate pain: 4-7 | |of the abortion process. | |positioning on a side-lying | | |

|Mild& tolerable:1-3 | | | |position, and therapeutic touch. |To control the pain felt and to | |

|No pain at all: 0 | | | | |promote partner participation. | |

| | |Pain preceded by vaginal | |Encouraged a complete bed rest and | | |

| | |bleeding, in the middle | |having adequate rest. | | |

| | |&intermittent. | | | | |

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| | | | |Observed for untoward signs and | | |

| | | | |symptoms like continuous increase | | |

| | | | |of pain felt by the patient. |To promote wellness and avoid | |

| | | | | |putting tension on the pain site.| |

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| | | | | |To prevent any other | |

| | | | | |complications and to implement | |

| | | | | |immediate action. | |

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