Assessment Diagnosis Scientific Goal Nursing Intervention Rationale Outcome

Explanation
Objectives: Acute Pain In abruption 1. Assess for To help
VS as follows: related to placenta, a Short term: referred pain determine the Short term:
 BP of 180/100 uterine common After 2 hours possibility of After 2 hours of
 PR of 110 contractions cause of of nursing underlying nursing
 RR of 22 during cramping is intervention, condition or intervention, the
initial round the patient’s organ patient rate of
separation ligament rate of pain dysfunction pain decreased
 Mild uterine pain. The will decrease requiring control of pain
contraction round from a scale treatment. from a scale of 8
 (+)Uterine ligament is a of 8 to at to 5 out of 10.
muscle that least 5 out of 2. Note client’s Individuals with
tenderness
supports the 10. locus of control. external locus of
 (+) Restless
uterus, and control may
 Conversant in when it
phrases take little or no
stretches, you Long term responsibility Long term
 (+) Sharp, may feel a
aching pain for pain
sharp, aching At the end of management
high in the pain, or a dull
uterine fundus the shift, At the end of the
ache in your patient will To rule out shift patients
 Pain scale of 8 lower 3. Note and
display worsening of displayed
out of 10 abdomen investigate
improved underlying improved well-
during last changes from
well-being condition or being such as
trimester of previous reports
such as development of baseline levels for
pregnancy. of pain
baseline complications. pulse, BP,
levels for respirations
pulse, BP, relaxed muscle
respirations tone and will be
relaxed painless.
muscle tone 4. Acknowledge Pain is a
and will be the client’s subjective
painless . description of experience and
pain and convey cannot be felt by
acceptance of others.
client’s response
to pain.
5. Monitor skin These are
color and usually altered
temperature and in acute pain
vital signs

6. Note when pain To medicate as

7. Provide comfort To promote non

8. Administer To maintain an
analgesics as acceptable level
indicated of pain

9. Encourage To prevent
adequate rest fatigue.
periods