Assessment Diagnosis Scientific Planning Implementation Rationale Evaluation

Background
Subjective data: Acute pain related to Short term: Independent: Independent: Short Term:
-“Nasakit unay toy inappropriate use of Unhealthy lifestyle After 6 hours of -Observe and record the -To potentially help the
tiyan ko. Diak kaya ti chemical agents as and Family health nursing interventions, ongoing pain being patient recover and be After 6 hours of
sakit nan.” verbalized evidenced history the patient will be experienced by the free of the existing nursing interventions,
by the patient. by weight loss, relieved of severe pain client. health disturbance the patient is relieved
-A pain scale 10/10 fatigue, positive with a 7/10 pain scale -Take and record vital experienced by the of severe pain being
with radiation in the guarding of the assessment. signs regularly. patient. experienced with 6/10
chest to back, abdomen, Improper usage of -Administer proper -To monitor and manage pain scale assessed by
-“Agkakapsot nak kada restlessness, facial medications Lon term: management of necessary and effective her. Therefore, the
kanayun nka nga grimace, and severe After 3 days of nursing medications prescribed ways or techniques for goal is met.
agsarwa iti nangisit.” pain assessed interventions, the by the doctor. the patient’s health
as verbalized by the through the 10/10 patient will be free of -Administer the client’s status.
patient. pain scale and the pain with a 0/10 proper meal diet and -To promote a safe and Long Term:
Irritation/Inflammatio
-Nausea, verbalization of pain scale, have her fluid intake. comfortable After 3 days of
n of the lining in the
-Frequent vomiting, "Nasakit unay toy stomach
facial grimace turned -Promote bed rest and a environment for nursing interventions,
-Bloating abdomen, tiyan ko. Diak kaya into a positive facial comforting environment patient’s faster recovery. the patient is already
-Coffee ground emesis, ti sakit nan." said by expression, and be back for client's faster -To guide or direct the free of the pain with a
-Black and tarry stool, the patient. to her comforting and recovery and relaxation. patient in going through 0/10 pain scale, a
-Weight loss, normal behavior. a healthy lifestyle and positive facial
-Fatigue Gastritis and Peptic Dependent: its benefits. expression is visibly
Ulcer -Prescribe effective seen, and she is back
Objective Data: medications such as Dependent: to her comforting and
-Positive guarding of Hyoscine N-Butyl -To provide proper normal behavior, so
abdomen, Bromide, Omeprazole medications for the she is already able to
-Restlessness, IV, Metoclopramide patient’s health concern perform activities and
-Facial grimace, and Kabiven for the to be resolved. actions without any
-Vital Signs taken as ff: patient to be able to -To establish the disturbances.
BP: 140/80mmHg recover. patient’s awareness and Therefore, the goal is
HR: 97 bpm -Give necessary pieces knowledge of the met.
RR: 21 cpm of information and existing health problem.
Temperature: 37.3 precautions regarding
degrees Celcius the patient’s existing
O2 Saturation: 97% health problem.
at room air
Height: 167 cm
Weight: 48 kgs