Explanation of the

Assessment Objectives Interventions  Rationale of Interventions Evaluation

Problem

 Acute pain in
Subjective: STO: Dx: STO:
pregnancy usually
 “Ang sakit sakit occurs due to the Within 30 minutes – 1  Assess for the  Using charts or drawings of the Within 30 minutes – 1
po ng tiyan ko” uterus pulling on the hour of effective location of the pain body can both help the patient hour of effective
as verbalized by round ligament. nursing interventions, by asking to point and the nurse in determining nursing interventions,
the patient. General aches due to the patient’s will to the site that is specific pain locations. For the patient verbally
uterine enlargement. verbally states relieved discomforting. clients with a limited reported decreased of
 Rated pain as Rectus muscle pain/ decreased pain. vocabulary, asking to pinpoint pain as being “much
8/10 haematoma - due to the location helps in clarifying better”.
 Characterized as rupture of inferior   your pain assessment.
 
dull pain. epigastric vessels in LTO:
late pregnancy. LTO:
 Pain is radiating Presents with sudden Within 24 – 48 hours  Perform history  Additionally, the nurse should
to her back. severe abdominal pain, of effective nursing ask the following questions Within 24 – 48 hours
assessment of pain.
 The pain relieves often after coughing or interventions, the during pain assessment to of effective nursing
trauma. patient will be able to determine its history: (1) interventions, the
when walking. 
respond immediately effectiveness of previous pain patient was able to
Objective: to any complaint of treatment or management; (2) respond immediately
pain and eliminate what medications were taken to any complaint of
 Report of pain. additional stressors or and when; (3) other pain and eliminate
 Self-focusing. sources of discomfort. medications being taken; (4) additional stressors or
allergies or known side effects sources of discomfort.
 Guarding  
behaviors. to medications.

 Autonomic
responses,  Some patients may be satisfied
restlessness  Determine the
patient’s when pain is no longer
(acute pain). massive; others will demand
anticipation for pain
  relief. complete elimination of pain.
This influences the perceptions
Nursing Diagnosis: of the effectiveness of the
treatment of the treatment
 modality and their eagerness to
 Acute pain
engage in further treatments.

 Some patients may be hesitant

to try the effectiveness of
nonpharmacological methods
and may be willing to try
 Assess the patient’s traditional pharmacological
willingness or methods (use of analgesics). A
ability to explore a combination of both therapies
range of techniques may be more effective and the
aimed at controlling nurse has the duty to inform the
pain. patient of the different methods
to manage pain.

 It is preferable to provide an
Tx:
 Provide measures to
relieve pain before
it becomes severe.
analgesic before the onset of
pain or before it becomes
severe when a larger dose may
be required. An example would
be preemptive analgesia which
is the administration of
analgesics before surgery to
decrease or relieve pain after
surgery.

 Promotes relaxation and helps

refocus attention.

 Provide
nonpharmacologica
l comfort measures
(massage,
repositioning,
 backrub) and
 Enables patient to participate
diversional
actively in nondrug treatment
activities (music,
of pain and enhances sense of
television).
control. Pain produces stress
 Encourage use of and, in conjunction with
stress management muscle tension and internal
skills or stressors, increases patient’s
complementary focus on self, which in turn
therapies increases the level of pain.
(relaxation
techniques,
visualization,
guided imagery,
biofeedback,
laughter, music,  May decrease inflammation,
aromatherapy, and muscle spasms, reducing
therapeutic touch). associated pain.
 Provide cutaneous
stimulation (heat or
cold, massage).  This information helps
Edx: establish realistic expectations,
confidence in own ability to
 Inform patient and handle what happens.
SO of the expected  To reduce stress and promote
therapeutic effects optimal pain relief without too
and discuss much dependence on
management of side pharmacological means.
effects.
 Educate the patient
about non-
pharmacological
methods such as
imagery distraction
techniques (reading
or listening to
music),
recommended
exercises, and
relaxation
techniques.