DIANA KYLA A.

PUNAY
BSN-DASH-6

1. Client C is a 16-year-old female complaining of lower abdominal and lower back pain. She said it is her 2nd day of
her menstrual period. She seldom experiences this and so far, this is the worse. Initial assessment data: T =
36.8°C, BP = 120/80mmHg, PR = 80bpm, RR = 18cpm; pain scale of 6/10, client presents abdominal muscle
guarding. As the clinic nurse, how do you plan to care for this client?

Assessment Diagnosis Inference Planning Intervention Rationale Evaluation

SUBJECTIVE Activity Activity Short Term: Explain and The use of After 4-5 hours
DATA: intolerance r/t Intolerance assist the patient relaxation and of the nursing
“ Patient pain defined as a After hours of with pain relief other non- intervention, the
verbalized 2nd state in which a nursing measures that pharmacological patient has
day of her person has intervention are non- strategies to verbalized the
menstrual period insufficient patient will be pharmaceutical reduce pain has understanding of
and so far the physiological or able to show and non- been shown to the inventions
worse lower psychological improvements of invasive. be helpful. given to improve
abdominal and energy to activity the patient's
lower back pain endure or tolerance, and Educate the Heat increases condition, and
” complete can perform patient with the vasodilation and the goal has
necessary or activities without use of warm muscle been met.
desired daily experiencing compress. relaxation that Patient was able
OBJECTIVE activities. pain. can relieve to feel less pain
DATA: abdominal as evidenced by
cramps. lower pain scale
BP: 120/80 on abdominal
mmHg Educate the Relaxation and lower back.
PR: 80 bpm patient with the techniques
RR: 18 cpm use of relaxation decrease
T: 36.8C techniques skeletal muscle
PS: 6/10 ( deep tension, which
breathing, reduces pain
meditation, intensity and
yoga, rest) improves
relaxation; blood
circulation and
oxygen demand
are also
improved.

Massage
Perform improves blood
massage on circulation,
abdominal and relaxes muscles
lower back. for an improved
range of motion.