Assessment Nursing Patient Goals Interventions Rationale Evaluation

Diagnosis
Subjective Altered comfort: 2-3 hours after  Monitor Patient was able
 “Masakit acute pain related nursing patient’s to verbalize
ang tiyan to abdominal intervention, the vital signs decreased level
ko” as enlargement patient will of pain
verbalized express  Position
by the decreased level patient Patient was
patient of pain comfortably observed to be
to promote relaxed and well-
Objective 2-3hours after comfort rested
 (+) nursing
Guarding intervention,  Encourage Patient was able
behavior patient will be patient to to tolerate pain as
 (+) Facial able to tolerate perform evidenced by
grimace pain as deep absence of facial
 VS as evidenced by breathing grimace and
follows: absence of facial exercises guarding
 BP- 155/80 grimace and behavior.
 PR- 98 guarding  Encourage
behavior patient to
 RR- 26
 Temp – ambulate as
4hours after tolerated
37.2
nursing
 Distended intervention,
abdomen  Administer
patient will Paracetamo
47inches appear relaxed l 500mg/tab
and able to rest. as ordered
 Assessment Nursing Diagnosis Patient Goals Interventions Evaluation
Fluid volume excess  Monitor
Objective related to liver patient’s vital
 Distended disease as evidenced signs
abdomen by abdominal 
47inches enlargement and
 Bipedal edema bipedal edema
 (+) fluid wave
test
 BP – 130/80

Assessment Nursing Patient Goals Interventions Rationale Evaluation

Diagnosis