Date / Time Focus Data Action Response

12-10-2020 Acute pain related to D> Received patient lying on bed, conscious “masakit tiyan niya”
7am inflammation of verbalized by the mother, Facial grimace.
tissues Abdominal guarding, Pain in RLQ, Pain scale of 10/10
A> Noted pain location, duration, intensity (0-10 scale), and
characteristics (dull, sharp, constant), Monitored VS, assessed to
Maintain semifowler's poison, Assessed patient to Move slowly and
deliberately, Provided comfort measure like back rubs and deep
breathing, Provided diversional activities, Removed noxious
Environmental stimuli, Administered analgesics as prescribed, Ensured
adequate hydration; may require intravenous fluids, Promoted rest
periods to promote relief, sleep, and relaxation.
R> patient verbalized relief from pain and rated it as 0/10 from 10/10.