ASSESSMENT EXPLANATION OF THE OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION
PROBLEM/ patophysiology
S: “my breasts are Acute pain as defined by NANDA GOAL: DX:
sore and tender but is the unpleasant sensory and
there is no milk emotional experience associated STO: After 3-5 hours of > Assess for vital signs and for potential >to have baseline and to STO:
with actual or potential tissue nursing intervention the types of pain that may be affecting client aid in understanding
coming out and Im damage, or described in terms of patient, reason for severity of Goal met if patient,
also in pain due to such damage (international pain associated with > demonstrated decrease
uterine cramping ” Association for the study of pain): >will demonstrate client’s condition, and level of pain
as verbalized by the sudden or slow onset of any decrease level of pain. point toward needed
patient. intensity from mild to severe and interventions for pain >demonstrated use of
with duration of less than 3 >will be able to management relaxation skills and
months. demonstrate use of diversional activities
relaxation skills and > in order to fully
O: T=36.5 , As for the condition of the patient, diversional activities as > Obtain client’s/significant other’s (SO) understand client’s pain >verbalized
BP=110/80, one of her main concern is pain indicated, for individual assessment of pain to Symptoms understanding the
RR=14, because there is a qi and blood situation include location, characteristics, onset, possible therapeutic
O2 Sat= 94% deficiency that causes weak body, duration, frequency, regimen
PR=78 blood loss, blood and qi weakening >will be able to quality, intensity. Identify
>edematous and blood that cannot move verbalized understanding precipitating or aggravating and Goal partially met if
perineum , as causing poor blood flow and lack the possible therapeutic relieving factors patient,
examined of nourishment that brings up pain regimen of her > to evaluate client’s >doesn’t demonstrated
and the qi deficiency opens the underlying condition > Evaluate pain characteristics and response to pain decrease level of pain but
> facial grimacing blood chamber and receives cold – intensity. Use pain rating scale demonstrated use of
>irritability blood clotting, obstructed placental LTO: After 72 hours of appropriate for age and cognition ( 0 relaxation skills and
membranes in the uterus, nursing intervention the -10 wherein 0 is the lowest pain and 10 diversional activities
emotional disorders- liver qi patient: indicating greater pain intensity)
stagnation leading to blood stasis >verbalized
Nursing Diagnosis:
>will have a reduction in > Ascertain client’s knowledge of and understanding the
Acute Pain related to and blocking that causes general > Provides baseline for
pain to a level of comfort expectations about pain possible therapeutic
uterine cramping and activation of immune system
leading to signs and symptoms that is acceptable to her Management. interventions and regimen
stretching of cervix
such as pain , uterine teaching, provides
and birth canal >will report pain is Goal not met if patient,
cramping ,fever, chills, chest opportunity to allay
secondary to relieved or controlled >totally no signs of
pain , fatigue, and muscle constrain common fears and
episiotomy decrease level of pain
misconceptions
>will follow prescribed > doesn’t understood the
pharmacological TX: use of relaxation skills
regimen. >Administer analgesics, as indicated, to and diversional activities.
> to maintain
maximum dosage, as needed, prescribed “acceptable” level of >doesn’t verbalized
>will be able to by the physician. pain. Notify physician understanding the
verbalized sense of if regimen is inadequate possible therapeutic
control of response to to meet pain control regimen
acute situation and goal. Combinations of
positive outlook in the medications may be used
future on prescribed LTO:
Intervals.
GOAL met if patient,
> To assist client to
> Provide or promote explore methods for >had reduction in pain to
nonpharmacological pain management: alleviation/control of a level of comfort that is
Quiet environment, calm activities pain. acceptable to her
Comfort measures (e.g., back rub,
change of position, use of heat or cold > reported pain is relieved
compresses) or controlled
Use of relaxation exercises (e.g., focused
breathing, visualization, > followed prescribed
guided imagery) Diversional or pharmacological regimen
distraction activities, such as television
and radio, socialization with others, > verbalized sense of
commercial or individualized tapes (e.g., control of response to
“white” noise, music, instructional) acute situation and
positive outlook in the
> Work with client to prevent pain. Use future
flow sheet to document >as timely intervention
pain, therapeutic interventions, response, is more likely to be GOAL partially met if
and length of time successful patient,
before pain recurs. Instruct client to in alleviating pain >had no reduction in pain
report pain as soon as it to a level of comfort that
begins is acceptable to her
> reported pain is not
relieved or controlled
EDX: But followed prescribed
pharmacological regimen
>Encourage verbalization of feelings >to evaluate coping
about the pain such as abilities and to identify >verbalized sense of
concern about tolerating pain, anxiety, areas of additional control of response to
pessimistic thoughts concern. acute situation and
positive outlook in the
future
> Acknowledge the pain experience and > Reduces defensive
convey acceptance of responses, promotes GOAL not met if patient,
client’s response to pain. trust, and enhances
cooperation with > had no reduction in
regimen pain to a level of comfort
> Encourage adequate rest periods that is acceptable to her
> to prevent fatigue that
can > reported pain is not
impair ability to manage relieved or controlled
or cope with pain.
>Identify specific signs/symptoms and >doesn’t followed
changes in pain characteristics > Provides opportunity prescribed
requiring medical follow-up. to modify pain pharmacological regimen
management regimen
and allows for timely >doesn’t verbalized sense
intervention for of control of response to
developing acute situation and
complications. positive outlook in the
future
