Assessment Explanation of the Problem
S:
 “Masakit yong tiyan
ko”
 Rated pain as 4/10
D:
 Grimace noted
 With guarding
behavior at Right
upper quadrant Fluid retention in the
 Distended abdomen
 Normoactive bowel
sound Abdominal distention
 Abdominal girth
82cm
 With limited
movement
A:
 Acute pain related to
abdominal distention
secondary to Ascites
Objective Nursing Intervention Rationale Evaluation
Alcoholism STO: Dx: STO:
|  After 8 hours of  Assess pain such as  Indications need for  The patient reports
Cirrhosis nursing intervention, severity, location, effectiveness of relief of pain, rest
| the patient will be intensity, frequency, interventions and comfortably and have
Complication able to relieve pain interval and may signal less frequent episode
| and discomfort. aggravating factors. development of of pain.
Ascites resolution of
| complications.
 Assess of coping  High coping
abdominal cavity mechanisms and use mechanisms and use
| of diversimal of diversimal
activities. activities may lessen
| pain.
Tissue trauma  Assess ability to  To determine the
| perform ADL. ability of the clients
Pain physical activity.
 Observe non-verbal  To determine
cues. indication of pain.
 Measure 88.5.  To know the
condition/fluid
retention in the
abdomen.
 Monitor vital signs.  Alterations from
normal may be signs
of infections.
Tx:
 Assist in performing  To promote non-
ADL’s such as pharmacological pain
arranging the things management.
and providing
bedside care.
 Promote rest by
scheduling
intervention in cluster
to prevent
aggravating of the
infection.
  Provide comfort such
as repositioning the
patient.
Edx:
 Encourage to use  To serve as
diversional activities destruction for
such as reading concentrating pain
books or listening to sensation.
music.
 Advise to verbalize  To give proper
progressing pain. interventions.
 Discuss possible  To prevent
dietary restrictions aggravation of the
such as alcohol and disease.
fatty foods.
 Encourage to  Helps in the
increase intake of nutritional status of
egg white. the patient.