JMJ Marist Brothers

Notre Dame of Marbel University

College of Arts and Sciences – Nursing Department
Alunan Avenue, Koronadal City, South Cotabato
Patient’s Name: _____Patient A. B.______ Age: 41 years old______ Sex: _Female___
Chief Complaints: Vaginal bleeding, nausea and vomiting, abdominal discomfort Diagnosis: ___G3P2 PU Threatened Abortion vs. Hydatidiform-mole

ASSESSMENT CUES NEEDS NURSING DIAGNOSIS BACKGROUND NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
INFORMATION
Independent:
Subjective: P Acute Pain related to Acute pain normally At the end of the 8-hour -monitor VS every 4hours -these are usually After the 8-hour nursing
H Hydatidiform mole as starts abruptly and nursing intervention, altered with acute pain intervention, the goal was
Patient verbalized, Y evidenced by a pain is of a sharp nature. the patient should -assess pain perception using -to know patient’s met.
“Masakit ang likod ko sa S scale of 5/10 as It acts as a warning report that the pain is a pain scale response to the pain
may bandang baba.” I verbalized by the patient sign for illness or a relieved or controlled managements being -patient reports no
“Sumasakit kung O potential danger to done presence of pain with a
gumagalaw ako pero L the body. Many Specifically, the patient pain scale of 0/10 from
nakakaya ko rin naman ang O incidents or should: -provide comfort measures -to promote non- 5/10
sakit.” G conditions may -have a pain scale of like touching and pharmacological pain
I cause acute pain, 0/10 from 5/10 repositioning, quiet management -followed comfort
Objective: C including: Surgical -follow both non- environment and calm measures and relaxation
-received the patient on Pain. pharmacologic and activities techniques provided by
semi-Fowler’s position, N pharmacologic pain the healthcare team
awake, conscious and E management -instruct and encourage -to distract attention
coherent. E -demonstrate use of relaxation techniques like DB and reduce tension -actively participated in
Pain scale: 5/10 D relaxation skills exercises, music and movie the pharmacological
Latest Vital Signs are as S watching therapies provided
follows:
BP: 120/90 Dependent:
CR: 98 bpm -administer pain medications -to help relieve and
RR: 21 cpm such as mefenamic acid and maintain acceptable
Temp: 37.0 degrees C continue Ketorolac IV as level of pain
O2 saturation: 99% ordered