RAY JUNDIE BUERANO ESTRADA AUGUST 31, 2014

BSN IV-GROUP 2
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:
kumikirot pa
rin ng aking
tiyan as
verbalized by
the patient

Objective:
Pain scale of
6 out of 10
as 10 as the
highest and
0 is the
lowest.
With facial
grimace
Guarding
behavior
noted
Restless and
weak in
appearance

Acute abdominal
pain related to
inflammation of
gallbladder.
After 2 hours
of nursing
interventions,
the patient will be
able to experience
gradual
reduction/relief
of pain.
1. Instruct client to
report any
improvement/
exacerbation in pain
experience.

2. Provide comfort
measures such as
use of incentive
spirometry or
blow bottles.

3. Encourage and assist
client to do deep
breathing exercises.




4. Provided emotional
support and
motivation.


5. Encourages
adequate rest and
sleep.
6. Encouraged to
perform diversional
activities such as
1. Unrelieved pain can
create other problems
such as anger, anxiety,
immobility,
respiratory problems,
and delay in healing.
2. To provide non-
pharmacologic pain
management.



3. Deep breathing
for relaxation is easy to
learn and contributes
to pain relief and/or
reduction by reducing
muscle tension and
anxiety
4. If the client is ill,
ascertain the
motivation for
returning to an optimal
level of wellness
5. To regain the clients
energy and to prevent
fatigue.
6. To distract the patient
from being in pain.

Goal met. After 2
hours of nursing
interventions,
the patient will be
verbalized relief from
pain and rated it as 3
out of 10.

texting, reading
newspaper, listening
to music and others.
7. Administer pain
medication as
prescribed by the
physician.



7. Necessary for
treatment of the
underlying cause.