Assessment Nursing Planning Implementation Rationale Evaluation

Diagnosis

Subjective: Acute pain After 30 Independent Independent Goal met if after

related to minutes to 30 minutes to 1
“Sumasakit ang Using a pain scale, Assessment and
edema, 1 hour of hour of rendering
tiyan ko, Nurse” assess pain level control of pain are
distention of rendering nursing
as verbalized by before and after important because
the pancreas, nursing interventions, the
the patient. administration of restlessness
and peritoneal interventio patient reported
analgesic. increases body
irritation as ns, the decrease in pain
metabolism, which
evidenced by patient will from 9/10 to 3/10
Objective: stimulates the
reports of pain report on the pain scale.
secretion of
 Facial with a pain decrease in
pancreatic and
grimacing  scale of 9/10. pain from
gastric enzymes.
9/10 to Goal unmet if
 Guarding 3/10 on the after 30 minutes
behavior  pain scale. to 1 hour of
Demonstration of
 Abdomen is rendering nursing
caring can help to
distended, interventions, the
firm, and Listen to the decrease anxiety. patient did not
tender in a patient’s expression report a decrease
diffuse of pain experience. in pain from 9/10
fashion to Decreases metabolic to 3/10 on the
light rate and GI pain scale.
palpation Maintain bed rest stimulation and
during an acute secretions, thereby
 Patient is reducing pancreatic
attack and provide a
lying on her activity.
quiet, restful
right side in
environment.
a semi fetal
position
Reduce abdominal
 Diaphoretic pressure and
tension, providing
 Restlessness Promote position of some measure of
comfort, such as on comfort and pain
 Heart rate is
one side with knees relief.
regular but
flexed or sitting up
tachycardic
and leaning
 Tachypneic forward. The use of
nonpharmacologic
methods will
Vital Signs: promote relaxation
Provide and enables the
BP: 100/70
nonpharmacologic patient to refocus
mmHg
HR: 97 bpm interventions for attention; may
relieving pain, enhance coping.
RR: 30 cpm
including
Temp. repositioning and
(tympanic): back rub, and quiet
100.2°F / 37.9°C diversional activities
such as TV or radio.
SpO2: 88% on Encourage
room air and relaxation
92% on 2 L of techniques, such as
oxygen by nasal guided imagery and
cannula visualization.

Keep the
environment free of Sensory stimulation
food odors. can activate
pancreatic enzymes,
increasing pain.

Report unrelieved If the patient

pain or increasing experiences
intensity of pain to increasing severity of
the physician. pain,

the nurse reports

this to the physician
because the patient
may be

experiencing
hemorrhage of the
pancreas, or the
dose of analgesic

maybe inadequate.

Dependent

Meperidine is usually
effective in relieving
Dependent pain. It acts by
Administer depressing the
analgesics such as central nervous
meperidine system and thereby
(Demerol) as increasing the
prescribed by the patient’s pain
physician. threshold.

Collaborative

This would provide

data and
visualization of the
Collaborative abdomen to identify
the cause of
Collaborate with abdominal pain.
other health care
team members
specifically medical
technologists and
radiology
technologists for
laboratory tests and
diagnostic
procedures.