CUES EXPLANATION OF THE PROBLEM PLANNING INTERVENTIONS RATIONALE CRITERIA FOR EVALUATION ACTUAL

EVALUATION
S> “Masakit pag Acute pain may be mild and last
pinipisil tsaka on just a moment. Or it may be severe Short Term: Diagnostic: Fully met if the patient: PARTIALLY
and off yung sakit” and last for weeks or months. In After 30-45minutes -Assessed pain -Indicates need for 1. Demonstrates use of MET
most cases, acute pain does not last of nursing characteristics and effectiveness of relaxation skills -Demonstrate
O> Pain rated as longer than 6 months, and it stops interventions, the responses interventions and 2. Reports lightly relaxation
8/10, located at when its underlying cause has been patient will be able to: may signal or totally relieved by skills.
the right lower treated or has healed. 1. Demonstrate development/resolut verbalizing pain -Reports lightly
quadrant use ion of complications. scale from 8/10 to or totally
For the case our patient with acute
aggravated by of relaxation -Assessed vital - For base line data. 4/10 relieved by
pancreatitis, pain was felt initially
movement, and on the epigastric pain which was skills signs 3. Be slightly or totally verbalizing
alleviated by rest. characterized to be squeezing, 2. Reports lightly - Checked - Indicate presence comfortable and pain scale from
>Sometimes localized, radiating pain and rated or totally laboratory results. of infection and less irritable 8/10- 5/10.
irritable as 10/10. After some days of relieved by dehydration. 4. Absence of -Shows less
>Facial grimace confinement, the patient’s pain was verbalizing pain Independent: grimacing, sighing grimacing,
whenever shifting felt in the Right Lower Quadrant of scale from 8/10 -Provide back rub -To provide comfort and moaning. sighing and
position the abdomen and was rated to be to 5/10 or position the and relaxation. Partially met if the patient: moaning.
>Always on bed 8/10 in severity, localized, non- 3. Be slightly or client to her 1. Demonstrate use
with limited radiating. The RLQ of the patient’s totally comfortable of relaxation skills
movement abdomen, pain was also felt upon comfortable position. 2. Reports lightly
>Moaning and deep palpation or when applying and less - Kept bed linen - To avoid pressure. or totally relieved by
sighing noted pressure and it was board-like. irritable dry and wrinkle verbalizing pain
>Pain upon deep 4. Shows less free. scale from 8/10 to
palpation at the grimacing and - Facilitated deep - to minimize pain 5/10
right lower Reference: moaning breathing 3. Be uncomfortable
quadrant. Ambardekar, N. (2017) Acute Pain exercises and irritable
> Vital signs of BP: retrieved on december 9, 2017 Long Term: -Create a quiet and -To provide comfort 4. Shows less
120/80 mmhg, from https://www.webmd.com/a- After 3 days of nursing non- disruptive and relaxation. grimacing, sighing
T:38.2 degrees to-z-guides/condition- intervention the environment and moaning.
Celsius, RR: 15/pain/pain-management patient will be able to -Offered fluids as -To minimize pain.
18cpm. PR: 1. Report relieves tolerated Not met if the patient:
93bpm, and of pain from - Diverted pain by -To provide comfort 1. Does not
SP02:93% at room 8/10 to 4/10 communication. and relaxation demonstrate use
air. 2. Feels of relaxation skills
comfortable as
 Laboratory results: manifested by 2. Reports no change
WBC= 16.3 no limitations Dependent: in pain scale
Neutrophils= 89. 3 on movements. 3. Be uncomfortable
Nursing Diagnosis: 3. No pain upon Administer pain -To decrease pain and irritable
Acute pain related deep palpation. relievers as 4. Still grimace, sigh
to infectious prescribed(Tramad and moans.
process. ol, HNBB)

Educative:

Instruct in use -To promote comfort

of relaxation
exercises such as
pursed lip
breathing

Encourage -To divert from pain

diversional
activities such as
reading or socialize
with other

Encourage -To prevent fatigue

adequate rest
periods

Reference: Tang, J. (2017) Acute pancreatitis. Retrieved on December 9, 2017 from https://emedicine.medscape.com/article/181364-overview#a3
Lowenfels, A. (2015) Acute pancreatitis: The latest etiology. Retrieved on December 9, 2017 from https://www.medscape.com/viewarticle/854953_2
 SAINT LOUIS UNIVERSITY
School of Nursing
LEVEL III

CASE PRESENTATION
Echipare, John Barry
Balanay, Sonia Marie
Balcanao, Jasmin Faye
Barao, Jasper Nazarene
Bawayan, Jobelle
Hangdaan, Stephanie