Name of the Client: A.
Age/Sex: 39/Male
Chief Complaint: Abdominal Cramping
Date / Cues
Time
N Subjective:
O “Sakit kaayo akong
V tiyan nurse. Kanang
E murag ginakumot sa
M kasakitbantog
B usahay maglisod ko
E og ginhawa.” As
R verbalized by the
patient.
2 • Patient
8 verbalizes the
level of pain as 7
2 out of 10.
0 C
2 Objective:
2 • Restlessness
was noted.
@ • Guarding
behavior was
7:00 noted.
AM • Abdominal
tenderness.
• Patient is
lethargic.
Ward: Room #: Bed #:
Attending Physician: Dr. Loreto Admitting Diagnosis / Impression: DKA
Need Nursing Patient Nursing Implementation Evaluation
Diagnosis Outcome Interventions
C Acute Pain related to abdominal At the end of 30 • Assist patient in 1 November 28, 2022
O cramping as evidenced by minutes of nursing semi-fowler’s @ 7:30 AM
G restlessness, grimaced face, interventions, the position or let
N guarding behavior, and patient will be able to patient assume “GOAL MET”
I tenderness. report relieved in pain position of comfort.
T discomfort by a pain Rationale: Semi-fowler’s The patient was able
I Rationale: scale of below 7 and position helps reduce to report relieve of
V Abdominal cramping is often no signs of guarding abdominal pressure and pain through a pain
E cause by constipation, Irritable behavior, tenderness, tension, thereby reduces scale level of 2 out of
- Bowel Syndrome, food allergies and grimaced face pain. However, patient 10, along are no
P and even food poisoning. Muscle completely. will naturally assume signs of guarding
E cramping in the abdominal cavity least painful position for behavior, grimace
R takes place when there is a relief. face, and abdominal
sudden and involuntarily tenderness.
E contraction of the muscles • Demonstrate and 2
P resulting to painful sensation encourage “Nurse okay okay na
T (Cleveland Clinic, 2021). Also, relaxation akong paminaw ron.
U another contributing factor as to techniques, such as Nawala na ang
A why abdominal spasm causes slow and deep kasakit sa akong
L pain is brought by breathing, tiyan gamay dili. Mga
vasoconstriction which inhibits the visualization, and 2 na lang ang level
P blood supply in the abdominal abdominal sa kasakit dili
A cavity leading to anoxia of muscle breathing. parehas ganina na
T fibers, hence manifests pain sakit jud kaayo mura
• Difficult to T (Bordoni, Sugumar, Varacallo, Rational: Relaxation gud ko naglisod og
aroused. E 2022). techniques refocuses ginhawa.” As
• ECG: Sinus R attention, reduce muscle verbalized by the
Tachycardia @ N References: tension, promote sense patient.
120bpm. of well-being, and 3
• Deep and Rapid Bordoni, B., Sugumar, K., & control or decreases
Breathing are Varacallo, M. (2022). Muscle discomfort.
observed. Cramps. PubMed; StatPearls Fhey Bernadette M.
VS: Publishing. Retrieved last • Encourage and Beltran, St. N
• RR: 32cpm November 25, 2022, from maintain full bed
• HR: 122 bpm https://www.mybib.com/tools/apa- rest.
citation-generator Rationale: This
minimizes stimulation 4
Cleveland Clinic (2021), Muscle and promotes relaxation.
Spasms: Causes, Treatment &
Prevention. Retrieved last • Apply hot compress
November 25, 2022, from on abdominal area.
https://www.mybib.com/tools/apa- Rationale: Heat packs
citation-generator relaxes outer stomach
muscles and probes
movement of the GI
Tract. Also, this
increases blood flow to 5
the affected area that
helps in reducing pain.

• Encourage the
patient to increase
oral fluid intake.
Rationale: Low amount
of fluid in the body may
reinforce progression of
dehydration for which
constipation follows.
With this, the large
intestine soaks up water
from the food waste
making the stool hard
and difficult to pass 6
which inflicts muscle
pain in the abdominal
cavity.

• Give health
teachings to the
patient to increase
fiber intake in the
diet.
Rationale: Having
sufficient fluid intake in
the body prevents
constipation. If ever
there is persistent
constipation then this
may cause irritation of
the GI tract, which can
lead to excessive
muscle contractions of 7
the abdomen.

• Administer pain
killer such as
Buscopan, if
prescribed.
Rationale: Buscopan
relives stomach pain by
allowing the GI Tract
and bladder relax by
reducing abdominal wall 8
contractions.

• Administer IV fluid,
PLR 1L @
120cc/hr, if
prescribed by the
physician.
Rationale: Lactated
Ringer’s solution has an
electrolyte concentration
similar to that of
extracellular fluid. Also, 9
this works for fluid
resuscitation to avoid
dehydration.
 • Reassess patient
for the
characteristic and
severity of pain
after administering
the medication.
Rationale: The patient
experiencing the pain is
the most reliable source
of information and by
doing this, it will help 10
nurses assess the
effectiveness and
possible side effects of
the medication.

• Check the Vital

Signs of the patient
every 30 minutes.
Rationale: Vital signs are
altered when patient is
under stress (i.e. pain),
specifically the
Respiratory Rate and
Blood Pressure.