Assessment Nursing Diagnosis Goals and Objective Nursing Interventions Rationale Evaluation

Subjective: Acute pain related to After 2 hours of nursing Independent Investigate pain Changes in location intensity are not but may Goal met. After 2 hours of
“masakit tiyan niya” inflammation of tissues interventions, the reports noting location, reflect developing complications nursing
verbalized by the patient will verbalize duration, intensity (0-10 scale), interventions, the patient
mother relief from pain and rate and characteristics (dull, sharp, verbalized relief from pain
it as 2/10 from 10/10. constant) and rated it as 0/10 from
Objective: 10/10.
Facial grimace. Maintain semifowler's poison Reduces abdominal station, thereby reduces
Abdominal guarding tension
Pain in RLQ
pain scale of 10/10 Move patient slowly and
deliberately. Reduced muscle tension or guarding which
VIS taken as follow may help pain of movement
T: 38.6 Provide comfort measure bike
PR: 122 back rubs and deep breathing. Promotes relaxation and may enhance
RR: 24 Provide diversional activities patient's coping abilities by refocusing
BP: 122/75 attention
Remove noxious
Environmental stimuli
Reduce nausea and vomiting, which can
increase intra-abdominal pressure or pain
Administer analgesics as
prescribed Reduces metabolic rate and aids in pain relief
and promotes healing
Ensure adequate hydration; may
require intravenous fluids Patients with abdominal pain may have a
diminished appetite, be NPO, or not want to
drink fluids. Assess and promote appropriate
fluid balance, which may requiring notifying
the provider of a decreased oral intake and
need for intravenous fluids to maintain fluid
balance.

Promote rest periods to promote .

relief, sleep, and relaxation.
One’s experiences of pain may become
exaggerated as a result of exhaustion. Pain
may result in fatigue, which may result in
exaggerated pain. A peaceful and quiet
environment may facilitate rest.