ASSESSMENT

Subjective:
ang sakit ng
tyan ko, sa
parting taas as
verbalized by the
patient.
Objective:
Tense facial

expression
Guarding

behavior
Pain scale of

8 out of 10
as 10 as the
highest and
0 as the
absence of
pain.
Restless and
irritable
BP: 150/90
RR: 34

NURSING
DIAGNOSIS
Acute Pain
abdominalupper right
quadrant
related to
the
inflammator
y process as
manifested
by facial
grimace

PLANNING
After 2 hours of
nursing
intervention, the
patient will:
Relieved
and
reduced the
presence of
pain
Reduced
the pain
scale from
severe to
moderate
Diminished
presence of
facial
grimace.

INTERVENTION
Observation
of vital signs.

Adjust the
position as
comfortable
as possible.

Teach the
patient
relaxation
techniques
breathing
deeply.
Collaboration
with the
medical team
in the
delivery of
therapy.

Identify and
limit foods
that cause

RATIONALE
By observing
vital signs,
expected to
know the
progress of
the patient.
By adjusting
the position as
comfortable as
possible,
expected that
the patient
comfort is
met.
By
encouraging
deep
breathing
relaxation
techniques
patients, are
expected to
reduce
perceived pain
patients.
Collaborate
with medical
team in the
provision of
therapy; the

EVALUATION
Goal met:
After 2
hours of
nursing
intervent
ion, the
patients
pain
scale
reduced
from
8/10
down to
5/10
No facial
grimace
noted.
Seen
sleeping
on bed
comforta
bly.

discomfort
such as spicy
foods and
carbonated
drinks.
COLLABORATIVE:
Administer
analgesic for
relief of pain
as prescribed.

client gets the

right patients
receive
therapy.
Helps relieve
pain
by neutralizing
stomach acid
and increasing
bicarbonate
and mucus
secretion

Reduces
abdominal
tension and
promotes
sense of
control.

ASSESSMENT

NURSING
DIAGNOSIS
Disturbed
body image
related to
biophysical
changes as
evidenced
by negative
feelings
about body
and abilities.

PLANNING
After 2 hours of
nursing
intervention, the
patient will:
Verbalize
understan
ding of
changes
and
acceptanc
e of self in
the
present
situation.
Identify
feelings
and
methods
for coping
with
negative
perception
of self.

INTERVENTION
Discuss
situation and
encourage
verbalization
of fears and
concerns.
Explain
relationship
between
nature of
disease and
symptoms.
Support and
encourage
patient;
provide care
with a
positive,
friendly
attitude.

Encourage
family/SO to
verbalize
feelings, visit
freely and
participate in
care.
Assist

RATIONALE
Patient is very
sensitive to
body changes
and may also
experience
feelings of guilt
when cause is
related to
alcohol or other
drug use.

Caregivers
sometimes
allow
judgmental
feelings to
affect the care
of patient and
need to make
every effort to
help patient feel
valued as a
person.
Participation in
care helps them
feel useful and
promotes trust
between staff,

EVALUATION

patient/SO to
cope with
change in
appearance;
suggest
clothing that
does not
emphasize
altered
appearance
(color of
clothes, etc).
Refer to
support
services.
Counselors,
psychiatric
resources,
social
service, clery
and alcohol
treatment
program may
help.

patient, and SO.

Providing
support can
enhance selfesteem and
promote patient
sense of control.

Increased
vulnerability
and concerns
associated with
this illness may
require services
of additional
professional
resources.