BALAN, ELMER ALEXANDREW V.

BSN 3A

DATE/TIME FOCUS DATA ACTION RESPONSE

04/5/2022 Abdominal Pain D> The client stated that she has a complete lack of energy to do
anything, a lack of appetite with 5-lb weight loss, constipation,
10:00
abdominal pain, and an inability to sleep more than 5 hour each night.

A> Monitor patient’s vital signs. Assessed for abdominal tenderness.

Administer Buscopan 10mg BID.
10:15 – 11:00

R> Patient’s vital signs are within normal range. ------------------ Elmer
V. Balan, R.N. The client manifested absence of abdominal tenderness.
------------------ Elmer V. Balan, R.N. Client’s feelings of pain subsided.
10:15 – 11:30
------------------ Elmer V. Balan, R.N.

Highest Priority Intervention:

- Administration of Buscopan (hyoscine butylbromide) 10 mg BID q12h to alleviate pain