LIST PRIORITY NURSING DIAGNOSIS

- Acute Pain
- Deficient Knowledge
- Imbalance Nutrition: Less than Body Weight

NURSING CARE PLAN

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS
Subjective: Acute Pain related to Within 4 hours of Observe and document Assists in differentiating After 4 hours of
She has started to notice obstruction/ductal nursing interventions, location of pain severity (0-10 cause of pain, and provides nursing interventions,
having a dull pain in her spasm as evidenced the patient will report scale), and character of pain. information about the the patient pain was
upper abdomen. by reports of pain, relieve of pain or relieved or controlled.
disease progression and
“Musamot r aba jud ug facial mask of pain, controlled. -Goal met
maka-kaon ko ug guarding behavior. resolution, development of
kanang oily na mga Note response to medication, complications, and
pagkaon”. as verbalized and report to physician if pain effectiveness of interventions
by the patient. is not being relieved -Severe pain not relieved by
Objective: routine measures may
T- 37.7 Promote bed rest, allowing indicate developing
P- 88 patient to assume position of complications or need for
RR- 20 comfort further intervention.
BP- 140/90 -Relieves pain and reduces
Use soft or cotton linens; intra-abdominal pressure
-Facial mask of pain calamine lotion, oil bath, cool
-Guarding Behavior or moist compresses as -Reduces irritation and
-pain at the upper indicated dryness of the skin and
abdomen Control environmental itching sensation
temperature
-Cool surroundings aid in
Encourage use of relaxation
techniques, e.g, guided
imagery, visualization, deep-
breathing exercises
Make time to listen to and
maintain frequent contact with
patient
Administer analgesics as
prescribe
minimizing dermal discomfort
-Promotes rest, redirects
attention, may enhance
coping
-Helpful in alleviating anxiety
and refocusing attention,
which can relieve pain
To provide relief pain to the
patient