ASSESSMENT NURSING ANALYSIS PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION

Subjective: Acute pain Cholelithiasis STG: After 6 Independent: GOAL MET.

related to hours if nursing >Asses location, >To asses >After 6 hours
“masakit ang inflammation intervention, characteristic, etiology or of nursing
tagiliran ko.” As and distortion the patient will onset, duration, precipitating intervention the
verbalized by of tissues. Surgical Incision report that the frequency, factors. patient’s pain
the patient. pain has quality, and was controlled
lessened from severity of pain. and relieved.
9/10 to 2/10.
Objective: Disruption of >Promote bed > Bed rest in
Skin Tissue, rest in low low fowler’s
>Guarding Muscle Integrity LTG: after 2 fowler’s position. position reduces >Goal was met
behavior days of nursing intra abdominal
>Facial grimace intervention, pressure.
>pain scale of the pain has
9/10 Simulation of already
sensory nerve subsided. >Use soft cotton >Reduces
endings linens, calamine irritation,
lotion, oil bath dryness of the
and cool or skin and itching
moist compress sensation.
as indicated.
Pain

>Control >cool
Environmental surrounding aid
temperature in minimizing
dermal
discomfort.
 >Encourage use >Promotes rest
of relaxation redirects
technique attention, may
enhance coping.

Collaborative:
>Administer
medication as
prescribed:

>Anticholinergics >Relives reflex

spasm or
smooth muscle
contraction and
assist with pain
management.

>Narcotics >Given to
reduce severe
Pain
FREDRICK PADERANGA
olfu