Patients name: E.

T Diagnosis: UGIB Date of Admission: Assessment Nursing Diagnosis Chronic pain related to abdominal cramps as manifested by the Pain scale of 6 for abdominal pains. - Exhibits facial grimace upon palpation of the abdomen. -Shows signs of Irritability - Restlessness

Age: 65

Planning

Nursing interventions

Rationale

Evaluation

Subjective: - Patient verbalized: Sumasakit dito ko (referring to abdomen), parang may naninigas sa loob

Objective: -Pain scale of 6 for abdominal pains. - Exhibits facial grimace upon palpation of the abdomen. -Shows signs of Irritability - Restlessness - Vs taken as follows: T: 36.8 PR: 81 RR: 21 BP: 110/70

Short Term: After 4 hours of nursing interventions, the patient will be able to: - Verbalize reduction/ relief of pain in the abdomen. - Feel and palpate abdomen without facial grimace and moaning. - Recite and demonstrate some nonpharmacologic ways to lessen pain.

Independent: -Provide comfort measures such as use of pillows under extremities and periodic wound cleaning on affected area. - Encourage and assist client to do deep breathing exercises. - Teach client and significant other about the nonpharmacologic ways to lessen the pain. - Instruct client to report any improvement/exacerbation in pain experience. - Encourage verbalization of feelings about the pain. - Physical Examination: Periodic auscultation of the abdomen for bowel sounds Inspection and Palpation for masses and tenderness. Dependent: - Administer medications, particularly analgesics, as prescribed. - Assist with laboratory/diagnostic studies as indicated. (e.g., abdominal X-ray)

To promote relief and wellness. Deep breathing exercises contribute to relief of pain To maximize opportunities for self-control over pain manifestations. Only the client can judge the level and distress of pain; pain management should be a team approach that includes the client. Necessary for management of underlying and possible complications.

After 4 hours of nursing intervention the patient verbalize reduction of pain, goal is half met due to the patient needs further examination and medical intervention.