Date: Chart:

8-4 pm F> Acute pain related to disease process as evidenced by pain scale of 7/10
secondary to hydatidiform mole

D> Received lying in bed with an IVF of D5LRS @800 level. With feeling of
discomfort and restlessness. With guarding behavior and facial grimace. With
indicated pain scale of 7/10. With VS as follows: T – 36.8 °C, PR – 72 BPM, RR– 22
CPM, BP – 130/80mmHg, SP02- 95%. “Masakit talaga dto sa may tyan ko”

A>Monitored skin color/temperature and VS. Assessed pain’s location,

characteristics, onset, duration, frequency, quality, intensity or severity and
precipitating factors and noted changes. Observed subjective description of pain
and acknowledge the pain experience. Provided comfort measures such as back
rub, heat or cold application. Positioned to semi fowler to relieve abdominal
tension or lateral sims to relieve dorsal pressures. Administered prescribed
analgesics. Encouraged use of relaxation technique, deep breathing exercise and
use of diversional activities to distract attention and reduce tension. Emphasized
verbalization of feelings for reporting pain or relief of pain completely.

R> After 4 hours of nursing intervention, the patient reports that the pain is
relieved/ controlled from 7/10 to 3/10

Perform a
comprehensive
assessment of
pain to include
location,
characteristics,
onset, duration,
frequency, quality,
intensity or
severity, and
precipitating
factors of pain.
Note changes.
Perform a
comprehensive
assessment of
pain to include
location,
characteristics,
onset, duration,
frequency, quality,
intensity or
severity, and
precipitating
factors of pain.
Note changes.