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ASSESSMENT

Subjective:
“ ang sakit ng tyan ko,
sa parting taas” as
verbalized by the
patient.
Objective:
 Tense facial



expression
Guarding
behavior
Pain scale of
8 out of 10
as 10 as the
highest and
0 as the
absence of
pain.
Restless and
irritable
BP: 150/90
RR: 34

NURSING
DIAGNOSIS
Acute Pain
abdominalupper right
quadrant
related to the
inflammatory
process as
manifested by
facial grimace

PLANNING

INTERVENTION

After 2 hours of
nursing intervention,
the patient will:
 Relieved and
reduced the
presence of
pain
 Reduced the
pain scale
from severe to
moderate
 Diminished
presence of
facial grimace.

 Observation of
vital signs.

 Adjust the
position as
comfortable as
possible.

 Teach the
patient
relaxation
techniques
breathing
deeply.
 Collaboration
with the medical
team in the
delivery of
therapy.

 Identify and limit
foods that cause
discomfort such
as spicy foods
and carbonated
drinks.

RATIONALE

EVALUATION

 By observing vital Goal met:
signs, expected to
 After 2
know the progress
hours of
of the patient.
nursing
 By adjusting the
interventio
position as
n, the
comfortable as
patient’s
possible, expected
pain scale
that the patient
reduced
comfort is met.
from 8/10
 By encouraging
down to
deep breathing
5/10
relaxation
 No facial
techniques
grimace
patients, are
noted.
expected to
 Seen
reduce perceived
sleeping
pain patients.
on bed
 Collaborate with
comfortabl
medical team in
y.
the provision of
therapy; the client
gets the right
patients receive
therapy.
 Helps relieve pain
by neutralizing
stomach acid and
increasing
bicarbonate and
mucus secretion

 Reduces abdominal tension and promotes sense of control.COLLABORATIVE:  Administer analgesic for relief of pain as prescribed. .

 Identify feelings and methods for coping with negative perception of self.  Encourage family/SO to verbalize feelings.ASSESSMENT NURSING DIAGNOSIS Disturbed body image related to biophysical changes as evidenced by negative feelings about body and abilities. suggest clothing that does not RATIONALE  Patient is very sensitive to body changes and may also experience feelings of guilt when cause is related to alcohol or other drug use. Explain relationship between nature of disease and symptoms. INTERVENTION  Discuss situation and encourage verbalization of fears and concerns. visit freely and participate in care.  Assist patient/SO to cope with change in appearance. friendly attitude. PLANNING After 2 hours of nursing intervention.  Participation in care helps them feel useful and promotes trust between staff. EVALUATION  . provide care with a positive.  Providing support can enhance selfesteem and promote patient sense of control.  Support and encourage patient. and SO.  Caregivers sometimes allow judgmental feelings to affect the care of patient and need to make every effort to help patient feel valued as a person. patient. the patient will:  Verbalize understandi ng of changes and acceptance of self in the present situation.

Counselors.  Refer to support services. psychiatric resources. social service. clery and alcohol treatment program may help. .emphasize altered appearance (color of clothes. etc).  Increased vulnerability and concerns associated with this illness may require services of additional professional resources.