NURSING CARE FORMAT PLAN

PROBLEM: abdominal pain

NURSING DIAGNOSIS: Altered comfort related to abdominal pain
TAXONOMY: Nutritional Metabolic intake
CAUSE ANALYSIS: abdominal comfort or distress is associated with indigestion, and is the most common symptom of GI dysfunction.
REFERENCE: Joyce M. Black, et.al. , Medical Surgical Nursing, Clinical Management for Positive Outcomes, 6th edition

CUES OBJECTIVE NURSING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE:
Patient verbalized, “ sakat kau 1. After 2 days of duty, pain
akong tiyan/puson” and he
pionted at the umbilical area.
OBJECTIVE:
Patient has difficulty in
moving and is irritable. From
0-10, pain can be rated as7.
LTO:
will be relieved and patient
resumes to his normal
physical activity.
STO:
1. After an hour of relaxation,
patient will be alleviated
from pain.
INDEPENDENT
1. Assess reports of
abdominal cramping or
pain, noting location,
duration, intensity (0-10
scale).Report changes in
pain characteristic.
2. Encourage patient to
assume position of
comfort., e.g. knees flexed
1. change in pain
characteristics may
indicate developing
complications
2. Reduces abdominal
tension and promotes sense
of control.

3. Provide comfort measures 3. promotes relaxation

(e.g. back rub, reposition)

4. Observe/record abdominal 4. May indicate developing

 distension, increased intestinal obstruction from
temperature, decrease BP. inflammation, or edema.

5. Place a pillow under the 5. aids in relaxing the

knees abdominal muscles