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Assessment Nursing diagnosis Scientific Planning Intervention Scientific rationale Evaluation

explanation
August 19, 2009 Short term outcome: independent: August 21, 2009
09:30pm Ulcer in gastric area 12:00pm
Acute pain related to After 1 day of nursing • Determine • Varies with
Subjective: hyper secretion of intervention the client client’s individual and Short term:
gastric juices as Release of chemical will be able to: acceptable situation.
Stated: evidenced by substances such as: • Report pain is level of Partially achieve
yellowish vomitus Bradykinin relieved/contr pain/control
“sobrang sakit ng and pain scale of olled goal • To promote After 1 day of nursing
tiyan ko noong isang 10/10 non intervention the client
araw , pabalik balik Bradykinin binds with • Follow • Provide pharmacologic can be able to:
nga eh.” prostaglandin and prescribed comfort al pain
histamine pharmacologic measures management. • Follow
al regimen example: prescribed
Objectives: touch, pharmacologic
Transmit signal to • Verbalize a repositioning, al regimen
spinal cord non use of heat
• Pain scale of pharmacologic (cold packs), • Verbalized
10/10 Transmit to Medulla al method that quite non
Oblongata provides relief. environment • To distract pharmacologic
• Observe and calm attention and al methods
evidenced of Perception of pain Discharge out come: activities. reduce that provides
pain tension. relief
After 2 days of • Instruct
nursing intervention in/encourage
• Pulse rate of the client will be able use of
90 beats per to: relaxation Discharge outcome:
Reference: medical
minute • Demonstrate techniques
surgical nursing: 11th such as Not Achieve
use of
• Facial mask edition volume 1 relaxation focused • Pain is a
Brunner and skills and breathing, subjective
Suddarath divisional imaging, experience After 2 days of
activities as CDs/tapes and cannot be nursing intervention
indicated for felt by others the client cannot be
individual • Accepts able to:
situation. client’s
description of
• Experiences pain. • Demonstrate
no Acknowledge use of
complications the pain • To promote relaxation
experience of accurate skills and
• Remains free client’s intake of divisional
of pain response to drugs activities as
between pain. indicated for
meals. individual
Collaborative: situation.

• Teach client • Experiences


about no
prescribe complications
medications
including • Remains free
name, of pain
dosage, between
frequency and meals.
possible side
effects. Also
identify
medication
such as
aspirin that
patient should
be avoided.

References: NANDA
499-502
Medical surgical
nursing handbook
page: 615