NURSING SCIENTIFIC GOAL OF NURSING

DATE CUES RATIONALE EVALUATION

DIAGNOSIS BASIS CARE INTERVENTION

Marc ROS Acute pain Definition Of After 1 INDEPENDEN After 1 day of

h 17, - The patient related to The Nursing day of T -Attention to nurse-patient
2021 was reported sudden Dx nurse- associated interaction, the
to have separation patient -Assess for signs may patient was
vaginal of placenta It is defined interacti signs and help the nurse able to :
bleeding, from the as the on, the symptoms in evaluating
severe relating to pain. pain. An -report relief or
uterine unpleasant patient
abdominal increase in control of pain
wall as and will be
pain and BP, HR, and as evidenced
evidenced emotional able to :
rapid uterine temperature by describing
contractions, by sharp, experience
-report may be satisfactory
occurred 3 stabbing arising from
relief or present in a pain level at a
hours prior to pain high actual or
control patient with 3 to 4 from a
her in the potential
of pain acute pain. scale of 0-10.
admission. uterine tissue
as
fundus damage or -Investigate -Changes in -display
- Experiences evidenc
described in pain reports, location or improved well-
continuous ed by
terms of such noting intensity are being such as
pain on the describi
damage. (location, not baseline levels
lower part of ng
her abdomen. duration, uncommon for pulse rate,
satisfact
- The patient intensity and but may reflect BP and RR:
Pathophysiol ory pain
feels a sharp characteristics) developing BP: 120/80
ogical Basis level at
or stabbing complications. RR: 20 cpm
Sensory a 3 to 4
pain and Pulse rate: 92
nerve from a - Comfortable
cramping -Educate the bpm
endings scale of positioning
whenever her patient to have
abdomen come into 0-10. may help the -verbalize non-
a bed rest.
aches. contact with a -display Allow her to patient in pharmacologic
painful relieving the al methods that
improve position herself
- Patient stimulus pain she feels. relieves pain
shows d well- in a
sending an
irritable mood being comfortable
impulse from such as way. -Optimum
and facial the nerve
grimace. baseline amount of rest
ending to the levels -Encourage the to help
spinal cord
-Before for pulse patient of prevent the
and brain.
admission, rate, BP adequate rest risk of fatigue.
Sudden or
the pain at and RR. periods and Pain is a
the abdomen slow onset of verbalizations subjective
BP:
and lower any intensity
140/90 of feelings experience of
back restricts from mild to RR: 25 about pain. the patient;
her physical severe with
movements. cpm may help
an alleviate the
Pulse
Assessment anticipated or rate:109 pain and
predictable bpm provide
- Blood end and a comfort.
Pressure: -
duration of - Provide
140/90 verbaliz - Promotes
less than 6 comfort
mm/Hg e non- relaxation and
months. measures, like
pharma may enhance
- Uterus is cologica deep breathing the patient’s
hard, l and back rubs. coping abilities
Rationale
palpable, methods Instruct in by refocusing
tender, and relaxation or
The brain that attention.
painful visualization
processes relieves
the pain pain. exercises.
Diagnostic sensation
Studies and quickly - To determine
makes a - Monitor vital if there are
Complete motor
Blood Count signs such as any significant
response in pulse rate, BP, changes and
(CBC) an attempt to RR and allow early
WBC- 12.4 cease the temperature as recognition for
K/ul (High) action well as skin prompt
causing the color. interventions. .
pain. Vital signs are
Usually an usually altered
identifiable due to acute
painful pain.
stimulus
related to an
injury, brief
disease DEPENDENT
process, -Medications
surgical to help
- Administer
procedure or treat/alleviate .
analgesics or
muscular the patient's
medications as
dysfunction. pain. To help
per ordered by
determine any
the physician.
allergies and
Monitor for any
side effects. .
adverse
effects.