Client : Mrs.

P
Care plan by : Shinta Devi
Date Initiated : 3-19-2021
NIM : 210142P

ASSESMENT NURSING GOAL & INTERVENTIONS EVALUATION

DIAGNOSIS OUTCOME
DS: Biological injury After nursing action 1. Observe nonverbal DS: The patient said
a) The patient says agents (inflammation for 1 x 24 hours, it is reactions to that sometimes his
"pain in the gut" of the gastric mucosa) hoped that the pain discomfort stomach still hurts
B. The patient's child will be reduced until 2. Assess pain DS: P: pain occurs
said that during it is gone with the comprehensively when eating Q: pain
illness the patient's following criteria: including (location, like vomiting R: pain
need for sleep is Pain Control: characteristics, and in the gut area Q: pain
disturbed He slept  Patients can onset, duration, intermittent
irregularly, starting at control pain frequency, quality, DO: Scale: 3
7:00 p.m., sometimes  Patient reports intensity of pain) The face looks
only 1-2 hours later less or less pain 3. Assess pain scale restless
waking up, then  DBN breath 4. Use therapeutic A: The goal has not
sleeping again. The frequency (16- communication so been achieved
patient often feels 24x / minute) that the client can P: continue the
restless, sleeps  Scale 0-1 of 4 express pain intervention
poorly, and is often The patient is not 5. Assess the factors (1-11)
Client : Mrs. P
Care plan by : Shinta Devi
Date Initiated : 3-19-2021
NIM : 210142P

awake at night due to restless Leukocytes that can cause pain to

abdominal pain dbn (4000-10,000 / arise
DO: cmm) 6. Instruct patient to
General Condition: get enough rest
Weak, restless, face 7. Control the
looks pain resistant. environment that can
RR: 32x / minute. affect pain
Irregular breathing 8. Monitor vital signs
rhythm 9. Teach about non-
P: pain occurs when pharmacological
eating (relaxation)
Q: pain feels like techniques to reduce
vomiting pain
R: pain in the gut 10. Describe the
S: 4 factors that can
Q: intermittent. influence pain
tenderness in the 11. Collaboration
solar plexus area with doctors in
Client : Mrs. P
Care plan by : Shinta Devi
Date Initiated : 3-19-2021
NIM : 210142P

18,100 leukocytes / administering drugs

cm