1. The patient, a 41-year-old female, presented with vaginal bleeding, nausea, vomiting, and abdominal discomfort and was diagnosed with a partial hydatidiform mole, a condition where abnormal cell growth in the uterus causes pain.
2. After 8 hours of nursing interventions focused on pain management, comfort measures, and mobility assistance, the patient's pain level decreased from 5/10 to 0/10 and she showed some improvement in her range of motion despite movements still causing pain.
3. The nursing goals were for the patient to have reduced pain, increased mobility within her range of motion, and participation in pharmacological and non-pharmacological pain management techniques.
1. The patient, a 41-year-old female, presented with vaginal bleeding, nausea, vomiting, and abdominal discomfort and was diagnosed with a partial hydatidiform mole, a condition where abnormal cell growth in the uterus causes pain.
2. After 8 hours of nursing interventions focused on pain management, comfort measures, and mobility assistance, the patient's pain level decreased from 5/10 to 0/10 and she showed some improvement in her range of motion despite movements still causing pain.
3. The nursing goals were for the patient to have reduced pain, increased mobility within her range of motion, and participation in pharmacological and non-pharmacological pain management techniques.
1. The patient, a 41-year-old female, presented with vaginal bleeding, nausea, vomiting, and abdominal discomfort and was diagnosed with a partial hydatidiform mole, a condition where abnormal cell growth in the uterus causes pain.
2. After 8 hours of nursing interventions focused on pain management, comfort measures, and mobility assistance, the patient's pain level decreased from 5/10 to 0/10 and she showed some improvement in her range of motion despite movements still causing pain.
3. The nursing goals were for the patient to have reduced pain, increased mobility within her range of motion, and participation in pharmacological and non-pharmacological pain management techniques.
1. The patient, a 41-year-old female, presented with vaginal bleeding, nausea, vomiting, and abdominal discomfort and was diagnosed with a partial hydatidiform mole, a condition where abnormal cell growth in the uterus causes pain.
2. After 8 hours of nursing interventions focused on pain management, comfort measures, and mobility assistance, the patient's pain level decreased from 5/10 to 0/10 and she showed some improvement in her range of motion despite movements still causing pain.
3. The nursing goals were for the patient to have reduced pain, increased mobility within her range of motion, and participation in pharmacological and non-pharmacological pain management techniques.
Subjective: P Acute pain Abnormal At the end of Independent: Independent After the 8-hour H related to proliferation the 8-hour 1. Monitor VS 1. These are nursing Patient Y abnormal of nursing every usually altered intervention, the verbalized, S proliferation trophoblastic intervention, 4hours. with acute pain. goal was met. “Masakit ang I of cells, also the patient 2. Assess 2. To know likod ko sa O trophoblastic known as should report pain patient’s 1. Patient may L cells. molar that the pain is perception response to the reports no bandang O pregnancy, relieved or using a pain presence of baba.” G causes controlled. pain scale managements pain with a I tissues to 3. Provide being done. pain scale of Patient C grow faster Specifically, comfort 3. To promote 0/10 from verbalized, than they the patient measures non- 5/10 “Sumasakit N should, should: like pharmacological kung E especially 1. Have a pain touching pain 2. Followed gumagalaw E during the scale of 0/10 and management. comfort ako pero D second from 5/10; repositioni 4. To distract measures nakakaya ko S trimester. This 2. Follow both ng, quiet attention and and rin naman condition will non- environme reduce tension relaxation ang sakit.” result to a pharmacologic nt, and techniques stomach with and calm Dependent provided by Objective: a large pharmacologic activities 1. To help the Pain scale: appearance. pain 4. Instruct relieve and healthcare 5/10 Moreover, the managements; and maintain team Latest Vital fast growth of and encourage acceptable level
99 Marist Brothers Notre Dame of Marbel University Alunan Avenue, City of Koronadal College of Arts and Sciences NURSING DEPARTMENT Signs are as these tissues 3. relaxation of pain. 3. Actively follows: can Demonstrate techniques participated BP: 120/90 sometimes use of like DB in the CR: 98 bpm cause the relaxation exercises, pharmacolo RR: 21 cpm ovary to ovary skills music and gical Temp: 37.0 to twist on movie therapies degrees C their blood watching provided O2 supply this saturation: will cause Dependent: 99% intense 1. Administer pressure and pain pain to the medication abdominal s such as and pelvic mefenamic area of the acid and patient. continue Ketorolac IV as ordered
100 Marist Brothers Notre Dame of Marbel University Alunan Avenue, City of Koronadal College of Arts and Sciences NURSING DEPARTMENT
Patient’s Name: A.B Age: 41 years old Sex: Female
Chief Complaints: Chief Complaints: Vaginal bleeding, nausea and vomiting, abdominal discomfort Diagnosis: G3P2 PU Hydatidiform Mole, Partial Date Admitted: April 25, 2021
Subjective: P Impaired Impaired At the end of Independent: Goal partially
The patient H mobility physical the 8-hour Independent met. verbalized: Y related to mobility is a nursing 1. Monitor After 8 hours “Masakit ang S pain as nursing intervention, patient VS; 1. Observe for of nursing likod ko sa I evidenced diagnosis the patient will: 2. Secure bed signs and intervention, may O by limited approved by 1. Have railings; symptoms the patient; bandang L range of the North decreased that the 1. Improved 3. Promote baba.” O motion, American pain scale ranged of rest and patient is in “Sumasakit G slowed Nursing level motion kung I movement Diagnosis 2. Be able to provide great pain. 2. Movement gumagalaw C and the pain Association, move comfort; 2. To prevent s still ako pero scale of defined as the within and the patient accompan nakakaya ko N 5/10. state in which range of 4. Encourage from falling ied with rin naman E an individual motion. off the bed pain patient to ang sakit.” E has a and avoiding D limitation in change position further injury. S independent, purposeful every 2 3. Resting and Objective: physical hours. sleeping is a Painscale: movement of good way to 5/10 the body or of Dependent: ease pain. Limited one or more Providing range of extremities. 1. Give pain comfort such motion medicine
101 Marist Brothers Notre Dame of Marbel University Alunan Avenue, City of Koronadal College of Arts and Sciences NURSING DEPARTMENT Slowed Carpenito- as as putting the movement Moyet, L. J. prescribed patient’s (2006). by the room in to Handbook of physician; desired nursing diagnosis. and temperature Lippincott 2. Consult and closing Williams & dietary to the blinds Wilkins adjust can help the nutritional patient rest needs. and sleep. 4. To prevent bed sores. Frequent position changes help reduce burdening pressure points for an extended period and reduce break down.
Dependent
1. Managing pai n is key to improving quality of
102 Marist Brothers Notre Dame of Marbel University Alunan Avenue, City of Koronadal College of Arts and Sciences NURSING DEPARTMENT life. Pain kee ps people from doing things they enjoy. It can prevent them from talking and spending time with others. It can affect their mood and their ability to think. 2. The dietician could adjust the patient’s meal according to the patient’s needs that could help her recovery.
103 Marist Brothers Notre Dame of Marbel University Alunan Avenue, City of Koronadal College of Arts and Sciences NURSING DEPARTMENT Patient’s Name: A.B Age: 41 years old Sex: Female Chief Complaints: Chief Complaints: Vaginal bleeding, nausea and vomiting, abdominal discomfort Diagnosis: G3P2 PU Hydatidiform Mole, Partial Date Admitted: April 25, 2021
Subjective: P Risk for A blood pressure At the end of Independent: 1. Bed rest is After the 8- - “Gusto ko H Injury r/t slightly above the the 8-hour 1. Instructed a simple hour nursing sana mag- Y elevated normal level (90- nursing patient to have intervention intervention, CR doc, S blood 120/60-90) is intervention, her bed rest that can be the goal was kaso medyo I pressure considered to be an the patient 2.Instructed applied to a met. nahihilo pa O elevated blood should avoid watcher to give patient who is ako” as L pressure. Some getting an environment experiencing The patient verbalized O physicians consider injured free from noise dizziness, to did not G this as avoid getting experience Objective: I prehypertension. Specifically, Dependent: injured. any injuries - BP: 130/80 C With this condition, the patient 1.Informed 2. Watchers caused by an a patient is likely to should: patient to should also increased N experience 1. Maintain resume her be level of Blood E dizziness which is bed rest; maintenance responsible Pressure. E much prone to 2. Take medication, for giving a Moreover, her D injuries such as maintenance Losartan stress-free blood S bumping on medication to 50mg/tab PO environment pressure also furniture. enhance OD AM, based for the faster improved blood on doctor’s improvement from 130/80 pressure order of the to 120/90. levels 2.Monitored patient’s Vital Signs q4h state. 3. Losartan is a maintenance medication
104 Marist Brothers Notre Dame of Marbel University Alunan Avenue, City of Koronadal College of Arts and Sciences NURSING DEPARTMENT used to treat high levels and maintain normal levels of blood pressure. 4. Vital signs monitoring will allow the nurse to determine if there are positive or negative effects of the interventions done.
