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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

S;
“sakit ako diri” Acute pain r/t After 2-3 hours 1.Established After 2-3 hours
as verbalized by inflammation of nursing rapport of nursing
the patient while and distortion of intervention, 2. Monitored v/s intervention, the
pointing to the the gallbladder patient will be 3.Administered pt verbalized
RUQ portion of aeb patient’s able to verbalize prescribed relieved from
the abdomen verbalization of pain is relieved medications pain and a PS of
“sakit ako diri” from a Ps of 4. Taught pt about 0
O; 6/10 to 0. the use of
-P; 6/10 relaxation
-Patient is techniques
having difficulty 5.Encouraged pt
in moving to rest
-slightly facial 6. Repositioned
grimace noted patient in a
-BP 110/80 comfortable
mmHg, PR 97 position
bpm, RR 22 7. Encouraged
cpm, T 36.0 C, verbalization of
O2 sat 99% feelings
8. Monitored the
pain felt by the
patient
9. Diverted pt’s
attention
10. Assisted pt
during ambulation
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
S;
“sakit ako diri” Acute pain r/t After 2-3 hours 1.Established After 2-3 hours
as verbalized by inflammation of nursing rapport of nursing
the patient while and distortion of intervention, 2. Monitored v/s intervention, the
pointing to the the gallbladder patient will be 3.Administered pt verbalized
RUQ portion of aeb patient’s able to verbalize prescribed relieved from
the abdomen verbalization of pain is relieved medications pain and a P of 0
“sakit ako diri” from a Ps of 4. Taught pt about
O; 6/10 to 0. the use of
-P; 6/10 relaxation
-Patient is techniques
having difficulty 5.Encouraged pt
in moving to rest
-slightly facial 6. Repositioned
grimace noted patient in a
-BP 110/80 comfortable
mmHg, PR 97 position
bpm, RR 22 7. Encouraged
cpm, T 36.0 C, verbalization of
O2 sat 99% feelings
8. Monitored the
pain felt by the
patient
9. Diverted pt’s
attention
10. Assisted pt
during ambulation

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