ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

SUBJECTIVE: Acute pain related After hours of shift  Assess pain After few hours of
to abdominal and nursing characteristics shift the patient
“Masakit ang tyan ko”
cramping and interventions, the (quality, severity, verbalized less pain,
as verbalized by the
ulcer as evidenced patient will verbalize location, onset and and rate it 2/10 from
patient.
by expression of lees pain to no pain duration) 7/10
pain and guarding or relief from pain  Vital signs taken and
behavior and rate it as 2/10 recorded/monitored
OBJECTIVE: from 7/10 hourly
Holding the stomach  Assess for cause/s
and rapidly breathing of pain

Pain level: 7/10

Vital Signs:

T= 38.5

P=129 bpm

BP= 85/60

RR= 28 cpm