A.

CURRENT PAIN MEDICATION (Include dosage and any side effects)

Take aspirin when the pain recurs and the use of antacids (mylanta) to relieve symptoms of vomiting, vomiting
of blood, abdominal pain, nausea, bowel movements and overcome irritation due to gastric erosion

B. WHERE IS PATIENT’S PAIN? C. DESCRIBE CAUSE OF PAIN, IF KNOWN

Have patient point to or trace area of pain. Consuming too much alcohol, smoking, sometimes eating too
If more than one site, label A, B, C, or D much especially spicy and sour food, and taking aspirin for a
long time

D. HOW DOES PAIN FEEL TO PATIENT?

Feeling uncomfortable, vomiting, vomiting of blood, stabbing
stomachache, nausea, and bowel movements
E. INTENSITY OF PAIN (Rate on Scale of 0-5)
INTENSITY
SITE A SITE SITE SITE
B C D
1.AT PRESENT 2
2.ONE HOUR
AFTER
MEDICATION
3.THREE AFTER
MEDICATION
4.WORST IT GETS
5.BEST IT GETS

F. FREQUENCY OF PAIN (Check one for each site)

FREQUENCY
SITE A SITE B SITE C SITE D
1. OCCASIONAL √
2. FREQUENT
3. CONSTANT
G. PATIENT’S VIEW OF PAIN
1. WHAT MAKES PAIN BETTER? By taking antacid (mylanta)
2. WHAT MAKES PAIN WORSE? Irritation in the stomach because most consume alcohol, smoke, spicy and
sour food
3. ANY ASSOCIATED SYMPTOMS? Vomiting, vomiting of blood, stomach ache, nausea, bowel movements
4. ARE THERE TIMES OF THE DAY/NIGHT WHEN PAIN IS WORSE? -
5. WHAT HAS HELPED CONTROL PAIN IN THE PAST? Taking aspirin for pain relief
6. WHAT IS PAI PREVENTING PATIENT FROM DOING? Take aspirin, avoid alcoholic beverages, not smoke,
reduce spicy food and acid
7. DOES PATIENT WANT SOMETHING DONE ABOUT PAIN? (If no, why not?) Yes, because the symptoms
that arise are quite severe so it is not enough if only given antacid drugs (mylanta), must do a physical
examination and supporting examinations such as endoscopy
8. COMMENTS: It is recommended to better maintain diet, avoid alcoholic beverages, smoking, reduce eating
spicy and sour foods

DATE May 13 2020 SIGNATURE OF ASSESSOR Niyan Ayu Saputri, S.Kep

Imprint Patient Identificationor Write-in Information Below

PAIN ASSESSMENT Patient’s Name Mr. Jonas Johnson
Medical Record No. 01 01 11