Assessment
After 3 hours of
Subjective:
“Masaki tang tiyan ko”
Objective:
(+)diaphoresis
(+)grimacing
(+)Guarding
abdominal area
(+)Narrowed
Focus(withdrawal from
social or physical
contact)
(+) Relief or distraction
behavior ( moaning,
seeking healthcare
team, restlessness)
Self-focused
Pain:
 Quality: sharp
 Severity: 5/10
 Location: Right
Upper, Abdominal
 Onset: sometime
sudden/ gradual
 Duration:
sometimes
intermittent/contin
uous
 Precipitating
factors: moving in
Diagnosis Analysis Planning Intervention Rationale Evaluation
Acute pain related to Pain, the fifth vital sign, Used as basis for any
nursing interventions: Taken Vital Signs After 3 Hours of
disease process is a very covert diagnosis and
nursing interventions:
condition in which a regimens.
Patient will
range of unpleasant
demonstrate use of The client was able to
sensations and a wide
non-pharmacological Educated patient about Patient education reply with questions
variety of upsetting
pain management medication and disease decreases anxiety and about his/her condition.
factors may be
process instances of deficient
experienced by the
Patient will follow knowledge with the The clients pain was
patient. It is the most
prescribed disease process. significantly reduced:
common reason for
pharmacological Pain scale : 3/10
seeking health care.
regimen
Prevents stress on
Instruct in/encourage The client was able to
Pain occurs as the muscles and avoids
Patient will verbalize proper body mechanics verbalize feelings and
result of many further worsening of
methods that provide or body posture. discomfort.
disorders, diagnostic injury.
pain relief
tests, and treatments.
Medical conditions that
Patient will verbalize
causes pain are as
sufficient relief of pain
follows: hypertension,
or ability to cope with Instructed patient to
angina, myocardial Pain perception and
incompletely relieved assess and report
infarction, pain relief are covert;
pain. efficacy of measures
thromboplebitis, DVT, therefore management
used.
pneumonia, lung of pain is best left to
cancer, ruptured patient’s judgment.
intervertebral disc,
upper GI bleeding, This is so that relief
Instruct patient to report
esophageal bleeding, procedures may be
pain promptly.
pancreatitis, sickle cell instituted immediately.
crisis, peritonitis, renal
calculi, hepatic/cystic
calculi, fractures,
burns, AIDS, cancer
and end of life
condition. Surgical
interventions such as
gastrectomy, cardiac
surgery, thyroidectory,
mastectomy and the
likes also cause pain.
In addition, it may also
arise from emotional,
psychological, cultural,
or spiritual distress. Its
highly subjective
 bed
 Relieving factors:
lying in bed still
nature means that its
assessment and
management presents
challenges to nurse.

The description of pain

T- 37.6 C is a social transaction;
P- 125 bpm thus, assessment and
management of it
R- 22 cycles/min require a good rapport
BP- 130/90 of the nurse and the
patient.

Submitted by: Khemberly Rose Yabut