ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Independent Pain is not always Goal met, patient

After 4 hours of present, but if has verbalized
“Naiilang ako kumilos Acute pain related to nursing Note reports of present should be relief of pain.
kasi nandun yung post surgical incision intervention the pain, including compared with
takot ko baka patient will location, duration, patient’s previous Reduced Pain Scale
bumuka yung tahi ko verbalize relief of intensity (5 out of 10 pain symptoms. from 5 to 3.
at may konting kirot pain. pain scale) This comparison
pa.” as verbalized by may assist in Demonstrated
the Reduce Pain Scale diagnosis of relaxed body
Patient from 5 to 3 etiology of bleeding posture and be
and development of able to sleep/rest
Demonstrate complications. appropriately.
relaxed body Review factors that
posture and be aggravate or Helpful in
OBJECTIVE: able to sleep/rest alleviate pain. establishing
appropriately. diagnosis and
Abdominal treatment needs.
guarding After 8 hours of Identify and limit
nursing foods that create Food has an acid
Restlessness intervention the discomfort neutralizing effect
patient will such as and dilutes the
verbalize relief of spicy or carbonated gastric contents.
facial pain. drink.
grimacing
-Patient is able to Encourage small,
ambulate without frequent meals Small meals
pain scale of 5 discomfort prevent distension
out of 10 and the release of
Encourage patient gastrin
to assume position Reduces abdominal
of comfort. tension and
promotes sense of
control.
 Patient may
receive nothing per
mouth (NPO)
initially. When oral
intake is allowed,
food choices
depend on the
diagnosis
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION