Mila Ramos, is a 60 year-old married woman from Antipolo Rizal was rushed in the ER due to severe

abdominal pain (Pain Scale 9/10) associated with nausea and vomiting. 4 hours prior admission, The
patient went to the local market to do grocery, she ate manggang hilaw with bagoong and a tall glass of
gulaman. Twenty minutes after eating she suddenly experienced the urge to defecate.  Then after that
she started feeling nauseous. She’s having a loose watery stool (seven times for the last 4 hours), she
vomits three times for the last four hours for about 1-2 cups per vomitus. 30 minutes before admission,
her son found her unconscious in the toilet thus rushed her to the hospital.

Upon assessment, you noted that she is pale and cold, she shows guarding behavior in the abdomen. 
VS: BP- 90/60, T: 38.3, P: 112, RR: 29. When you asked her about her symptoms she stated: “Nurse ang
sakit sakit ng tiyan ko, parang washing machine, ikot ng ikot”.

1. Write the subjective and objective data. (20 points)

2. List at least three problems in this case. (10 points)
3. Formulate three nursing diagnosis. (10 points)
4. Write three planning statement in those three nursing diagnosis. Write the goal and expected
outcomes. (10 points)

ANSWERS:

1.
Subjective
● Severe abdominal pain (Pain Scale 9/10)
● Nausea and vomiting
● Experienced the urge to defecate
● She’s having a loose watery stool
● “Nurse ang sakit sakit ng tiyan ko, parang washing machine, ikot ng ikot”.

Objective
● VS: BP- 90/60, T: 38.3, P: 112, RR: 29.
● She is pale and cold
● She shows guarding behavior in the abdomen

2.
● She was rushed in the ER due to severe abdominal pain (Pain Scale 9/10)
● She ate manggang hilaw with bagoong and a tall glass of gulaman
● She vomits three times for the last four hours for about 1-2 cups per vomitus.

3.
● Severe pain related to inflammatory process as evidenced by the patient rating pain 9/10

● Vomiting related abdominal pain evidenced by the patient vomits three times for the last four hours
for about 1-2 cups per vomitus.
● Diarrhea related to presence of toxins as evidenced by the patient having loose watery stool seven
times for the last 4 hours.

4.
GOAL EXPECTED OUTCOMES
Severe pain related to Monitor signs and Shows no signs of pain
inflammatory process symptoms
as evidenced by the Vital signs within
patient rating pain 9/10 After 8 hrs of nursing normal range.
interventions, the
patient was able to
verbalized accepltable
level of pain relief and
ability to engage in
desired activities.

Vomiting related Assess the duration, Experience minimal

abdominal pain frequency, and nature nausea and vomiting
evidenced by the of nausea and vomiting
patient vomits three and any aggravating
times for the last four and alleviating factors
hours for about 1-2 to plan appropriate in
cups per vomitus.

Diarrhea related to To reduces frequency of Report relief of diarrhea

presence of toxins as stools
evidenced by the
patient having loose
watery stool seven
times for the last 4
hours.