Cues Subjective: - Patient verbalized: ³Sumasakit dito ko (referring to abdomen), parang may naninigas sa loob«dati pa to eh, medyo bata bata

pa ko.´ Objective: -Pain scale of 6 for abdominal pains. - Exhibits facial grimace upon palpation of the abdomen. -Shows signs of Irritability - Restlessness Vital Signs: BP ± 120/80 PR ± 87 bpm RR ± 32 breaths/min Temp ± 37.4

Nursing Diagnosis Chronic pain related to abdominal cramps secondary to non-ulcer dyspepsia

Goals and Objectives Long Term: After 3 days of nursing intervention the patient will be able to experience gradual reduction / relief of pain from a pain scale of 6 to at least 3. Short Term: After series of nursing interventions, the patient will be able to: - Verbalize reduction/ relief of pain in the abdomen. - Feel and palpate abdomen without facial grimace and moaning. - Recite and demonstrate some nonpharmacologic ways to lessen pain.

Nursing interventions Independent: -Provide comfort measures such as use of pillows under extremities and periodic wound cleaning on affected area. - Encourage and assist client to do deep breathing exercises. - Teach client and significant other about the nonpharmacologic ways to lessen the pain. - Instruct client to report any improvement/exacerbation in pain experience. - Encourage verbalization of feelings about the pain. - Physical Examination: Periodic auscultation of the abdomen for bowel sounds Inspection and Palpation for masses and tenderness. Dependent: - Administer medications, particularly analgesics, as prescribed. - Assist with laboratory/diagnostic studies as indicated. (e.g., abdominal X-ray)

Rationale

Evaluation

To promote relief and wellness. Deep breathing exercises contribute to relief of pain To maximize opportunities for self-control over pain manifestations. Only the client can judge the level and distress of pain; pain management should be a team approach that includes the client. Necessary for management of underlying and possible complications.

pain management should be a team approach that includes the client.Verbalize reduction/ relief of pain.Encourage verbalization of feelings about the pain.Patient verbalized: ³Ang sakit nun (pointing to left lower leg). . .Discuss with client and relatives the importance of proper positioning and mobilization. Only the client can judge the level and distress of pain.Recite and demonstrate some non-pharmacologic ways to lessen pain.Have normal respiratory rate. .Provide comfort measures such as use of pillows under extremities and periodic wound cleaning on affected area.Exhibits facial grimace and moaning upon movement of the left lower leg.Instruct client to report any improvement/exacerbation in pain experience. .Cues Subjective: .Pain scale of 8 for pain felt at the left lower leg. .4 Nursing Diagnosis Acute pain related to immobility / improper positioning Goals and Objectives Long Term: After 8 hours of nursing interventions.Encourage mobilization of the left lower extremity. . kumikirot!´ Objective: .Teach client and significant other about the nonpharmacologic ways to lessen the pain.Restlessness -Physical immobility Vital Signs: BP ± 120/80 PR ± 87 bpm RR ± 32 breaths/min Temp ± 37.Administer medications. Assist with ROM exercises. . Rationale Evaluation To promote relief and wellness. . -Shows signs of Irritability . Nursing interventions Independent: .Move her left lower extremity without facial grimace .. . Dependent: . the patient will be able to experience gradual reduction / relief of pain from a pain scale of 8 to at least 4.. .Encourage and assist client to do deep breathing exercises. Deep breathing exercises contribute to relief of pain To promote circulation and prevent excessive tissue pressure To maximize opportunities for self-control over pain manifestations. as prescribed. the patient will be able to: . particularly analgesics. Short Term: After series of nursing interventions.

Teach client and relatives about importance of proper positioning and keeping edematous feet elevated and clean. the patient will be able to: -Identify causative factors affecting fluid retention.Restlessness .Administer Medications. Nursing interventions Independent: -Assist in periodic positioning every 2 hours.Cues Objective: . shiny skin on lower extremities -Fluid intake greater than output Vital Signs: BP ± 120/80 PR ± 87 bpm RR ± 32 breaths/min Temp ± 37. -Identify dietary intake and habits that contribute to fluid retention.4 Nursing Diagnosis Excess Fluid Volume related to impaired venous return secondary to immobility Goals and Objectives Long Term: After 3 days of nursing intervention. -Protect edematous extremities from injury. the patient will exhibit decreased edema on lower extremities and stabilize fluid volume I&O. . -Monitor I&O and amount of fluid intake from all sources and calculate fluid volume imbalance. Short Term: After 8 hours of nursing intervention. Rationale Evaluation To prevent pressure ulcers To monitor kidney function and fluid retention To prevent injury and promote wellness To impart knowledge regarding present condition To promote circulation and prevent excessive tissue pressure .Periodically wash between skinfolds and dry carefully. -Relate causative factors affecting fluid retention. Dependent: .Irritability -Presence of edema on lower extremities -Taut. .