ASSESSMENT

NURSING DIAGNOSIS

NURSING CARE PLAN PLANNING INTERVENTION

RATIONALE

EVALUATION

Subjective: “sumasakit ang aking tiyan” as verbalized by the patient. Objective: Facial grimace Restlessness Reduced interaction with other people or environment Pain scale of 5/10

Acute pain related to After 4 hours of underlying illness as nursing intervention, manifested by facial patient’s pain will be grimace, restlessness, relief. reduced interaction with other people or environment, and pain scale of 5/10.

1. Perform pain 1. To rule out After 4 hours of assessment each time worsening of underlying nursing interventions, pain occurs. condition/development patient’s pain was of complications. relieved. 2. To help determine 2. Assess for possibility of underlying referred pain as condition or organ appropriate. dysfunction requiring treatment. 3. It usually altered in acute pain. 3. Monitor vital signs. 4. It helps in giving the patient relaxation. 4. Provide quiet environment. 5. To provide nonpharmacologic pain 5. Provide comfort management. measures such as back rub and changing of position.

8. This will lessen the pain of the patient.6. ASSESSMENT DIAGNOSIS NURSING CARE PLAN PLANNING INTERVENTION RATIONALE EVALUATION . 7. Encourage adequate rest periods. Encourage diversional activities such as watching TV or listening to radio. 8. 7. To prevent fatigue. To lessen the pain. 6. Administer analgesics as prescribed.

frequency and amount. • Bowel sounds are generally decreased in constipation • For presence of distention.2 PR= 95 RR= 25 Bp= 100/70 After 2 hours of nursing intervention. restlessness and Objective: discomfort.Subjective: Altered Bowel elimination “hindi ako masyado related to makadumi” as decreased dietary verbalized by the pt intake as manifested by Abdominal pain. College of nursing . • Abdominal pain • Restlessness • Discomfort • v/s taken as follow: T= 38. • Auscultate bowel sounds • Palpate abdomen • Encourages fluid intake • Encourages a diet of balanced fiber and bulk • Assist in identifying causative and contributing factors and appropriate intervention. masses • To enhance easy defecation • To improve consistency of stool and facilitate through colon. consistency. the pt was able to establish or return to normal patterns of bowel functioning SOUTHEAST ASIAN COLLEGE INC. the pt will establish or return to normal patterns of bowel functioning • Determine stool color. After 2 hours of nursing intervention.

Iso. Sonia G. Rafunzel B. Lopes. Lucas.R. Anna Sherrie B. Aaron S. Javar. Madeleen A. De Leon . Lagaras.In partial Fulfillment for the Requirements in Related Learning Experience NCM 205 Case study of “Hepatobiliary Tuberculosis” Submitted by: Guillermo. Maderazo. Jean Irish J. Joven. Maria Vida T. Kathrina D. Submitted to: Mrs.

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