GENERAL SANTOS DOCTORS’ MEDICAL SCHOOL FOUNDATION INC.
NCM: 109n RLE EXPOSURE
Area: GSDH WARD
Patient: Mr. Alex Santos Attending Physician: Dr. Shaun Murphy
Age and Sex: 56/Male
Chief Complaint: Abdominal pain
ASSESSMENT DIAGNOSIS AND
INFERENCE
Subjective Cues: Ng Dx:
S-“sakit akong tiyan ma’am Abdominal pain related to
mga 8/10 ang kasakit, wala present illness condition
sad ko gana magkaon
tungod sa kasakit” as Inference/ Background
verbalized by patient. Knowledge:
Abdominal pain occurs
Objective Cues: when mechanical or
chemical stimuli trigger the
-restlessness pain receptors in the
- tense abdomen. Stretch is the
-crying primary mechanical
-Facial Grimace stimulus. Other
-Guarding of abdomen mechanical stimuli, such as
expansion, contraction,
compression, pulling, and
twisting of the viscera, also
induce pain.
Reference:
https://www.lecturio.com/
magazine/abdominal-pain/
Inclusive Dates:
Students Name: Kusain, Jaya Normina R.
Diagnosis: Adenocarcinoma
NURSING CARE PLAN
OBJECTIVES NURSING INTERVENTION
Goal: Independent:
After 8 hrs of shift 1. Establish a rapport that enables
patient will verbalized client/ partner to feel comfortable
relieve of pain from asking questions.
8/10 to 4/10.
2. Assist client to use relaxation
techniques such as,
-deep breathing techniques
- guided imagery
-refocusing attention
-proper positioning.
3. Encourage and assist client with
change of position.
Dependent and Collaboration:
1. Administer pain reliever as
ordered by the physician.
2. Collaborate with the family in in
giving intervention to the patient.
Year and Section: BSN3
Group: 1-B
RATIONALE EVALUATION
1. Answers to questions can Goal met. Patient
alleviate fear and promote verbalized ease of
understanding. pain and rated 4/10.
2. Encourages relaxation and
gives client a means of coping
with, and controlling the level
of, discomfort
3. Prevents/limits muscle
fatigue; enhances circulation.
1. Phamacological agents helps
the pain relieves fast.
2. Collaboration with the family
in the treatment is helpful to the
patient health outcomes.