F > Acute Pain related to Hepatic Tumor T/C Abscess R/O Carcinoma (SURG WARD)

D > Received asleep lying on bed with an ongoing IVF of PNSS 1L x 24 hours @ right hand and
TNA 763kcal x 24 hours @ left hand. “Masakit itong likod ko.” as verbalized by the patient.
Rated pain as 6 out of 10. Facial grimacing noted. Needs partial assistance in doing activities of
daily life. Irritability noted. Guarding behavior is observed. With vital signs as follows: BP:
120/70; PR: 73bpm; RR: 20cpm; T: 36.7 C; SpO2: 96%.
A > Assessed for current health status and breathing status. Assessed pain through a pain scale
method. Assessed severity of pain by observing behavioral pattern. Assessed pain location.
Monitors and recorded vital signs. Provided comfort measures by re-positioning to relieve pain.
Provided safety measures by raising the side rails and by frequently checking. Assisted on doing
activities of daily life. Provided non-pharmaceutical pain management such as back rubbing.
Encourage to promote relaxation exercises such as deep breathing. Instructed client to increase
fluid intake. Instructed client to report untoward signs and symptoms.
R > Reported pain is slightly relieved. Pain rated 2 out of 10.
> Endorsed for further care and management.