Nursing Diagnosis: Acute pain related to liver enlargement secondary to ascites as evidenced by facial grimace, irritability, restlessness, anxiety,

fatigued, agitation, pallor,

guarding of body part and verbalization of pain with a pain scale of 4/10, and decreased in activity tolerance
NANDA Definition: Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (International
Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end, and with a duration of less than 3 months.

CUES NOC NIC EVALUATION

Subjective: NOC 1: Pain Level NIC 1: Pain Management NOC 1: Pain Level

 “Kapoy akong 210201 Reported pains  Performed a comprehensive 210201 Reported pains
lawas pirme”, 1 2 3 4 5 assessment of pain: location, 1 2 3 4 5
as client stated. 210204 Length of pain episodes characteristics, onset/duration, 210204 Length of pain episodes
 “Kapoy 1 2 3 4 5 frequency, quality, intensity or 1 2 3 4 5
lingkod, gusto severity of pain, and precipitating 210206 Facial expression of pain
210206 Facial expression of pain
ra ko mag factors 1 2 3 4 5
1 2 3 4 5 210208 Restlessness
higda pirme”,  Observed for nonverbal cues of
as client 210208 Restlessness discomfort, especially in those 1 2 3 4 5
verbalized. 1 2 3 4 5 unable to communicate effectively 210223 Irritability
 (+) Body 210223 Irritability  Assured patient attentive analgesic 1 2 3 4 5
weakness noted 1 2 3 4 5 care 210224 Wincing
 Pain Scale: 210224 Wincing  Used therapeutic communication 1 2 3 4 5
4/10 strategies to acknowledge the pain 210226 Diaphoresis
1 2 3 4 5
experience and convey acceptance 1 2 3 4 5
210226 Diaphoresis 210209 Muscles tension
of the patient’s response to pain
1 2 3 4 5 1 2 3 4 5
Objective:  Explored patient’s knowledge and
210209 Muscles tension 210215 Loss of appetite
 Normal Gait beliefs about pain
1 2 3 4 5 1 2 3 4 5
when walking,  Determined the impact of the pain
210215 Loss of appetite 210227 Nausea
no deviations experience on quality of life: sleep,
1 2 3 4 5 1 2 3 4 5
noted appetite, activity, cognition, mood,
210228 Food intolerance
 ROM Upper 210227 Nausea relationships, performance of job,
1 2 3 4 5
Extermities: 4 1 2 3 4 5 and role responsibilities
210210 Respiratory rate
(Good) 210228 Food intolerance  Explored with patient the factors
1 2 3 4 5
 ROM Lower that improve/worsen pain
1 2 3 4 5 210212 Blood pressure
Extremities: 3  Evaluated past experiences with 1 2 3 4 5
210210 Respiratory rate
(Fair) pain to include individual or family
1 2 3 4 5 history of chronic pain or resulting
 Able to move Legend:
Upper 210212 Blood pressure disability, as appropriate
1- Severe deviation from normal range
Extremities 1 2 3 4 5  Provided information about the
2- Substantial deviation from normal range
without pain: such as causes of the pain,
3- Moderate deviation from normal range
assistance and Legend: how long it will last, and
4- Mild deviation from normal range
against 1- Severe deviation from normal anticipated discomforts from
5- No deviation from normal range
resistance range procedures
 Able to move 2- Substantial deviation from  Control environmental factors that
Upper normal range may influence the patient’s
Extremities 3- Moderate deviation from response to discomfort (e.g., room
 without normal range temperature, lighting, noise)
assistance but 4- Mild deviation from normal  Reduced or eliminate factors that
with slight range precipitate or increase the pain
problems 5- No deviation from normal experience: fear, fatigue,
against range monotony, and lack of knowledge
resistance  Consider the patient’s willingness
 (+) Facial to participate, ability to participate,
grimace when preference, support of significant
Lower others for method, and
Extremities are contraindications when selecting a
pushed against pain relief strategy
resistance  Selected and implement a variety
 Height: 147.30 of measures: pharmacological,
cm nonpharmacological,
 Weight: 39 kg interpersonal to facilitate pain
 BMI: 18.0 relief, as appropriate
(underweight)  Taught principles of pain
management
 Consider type and source of pain
Labs & Dx Tests: when selecting pain relief strategy
 Encouraged patient to monitor own
 Hypokalemia pain and to intervene appropriately
3.19 mmol/L  Use pain control measures before
(3.5 – 4.4) pain becomes severe
 Hemoglobin:  Verified level of discomfort with
11.6 g/dL patient, note changes in the
(13-16) medical record, inform other health
professionals working with the
 Hematocrit:
patient
35.7%
 Evaluated the effectiveness of the
(37-49)
pain control measures used
through ongoing assessment of the
pain experience
 Provided accurate information to
promote family’s knowledge of
and response to the pain
experience
 Incorporated the family in the pain
relief modality, if possible
 Monitored patient satisfaction with
pain management at specified
intervals
NOC 2: Activity Tolerance NIC 2.1: Activity Therapy

000503 Respiratory rate with activity  Determined patient ability to NOC 2: Activity Tolerance
1 2 3 4 5 participate in specific activities
000508 Ease of breaking with activity  Determined patient commitment in 000503 Respiratory rate with activity
1 2 3 4 5 increasing frequency and range of 1 2 3 4 5
000504 Systolic Blood pressure 000508 Ease of breaking with activity
activity
1 2 3 4 5 1 2 3 4 5
000505 Diastolic Blood Pressure  Assisted patient in exploring the
000504 Systolic Blood pressure
1 2 3 4 5 personal meaning of usual activity
1 2 3 4 5
000509 Waking pace and favorite leisure activity
000505 Diastolic Blood Pressure
1 2 3 4 5  Assisted patient to focus on 1 2 3 4 5
000516 Upper body strength abilities, rather than on deficits 000509 Waking pace
1 2 3 4 5  Assisted patient to choose 1 2 3 4 5
000517 Lower body strength activities and achievement goals 000516 Upper body strength
1 2 3 4 5  Encourage creative activity 1 2 3 4 5
000518 Ease of performing ADLs 000517 Lower body strength
 Instructed patient and family
1 2 3 4 5 1 2 3 4 5
regarding the role of physical,
000514 Ability to speak with physical 000518 Ease of performing ADLs
activity social, spiritual, and cognitive
1 2 3 4 5
1 2 3 4 5 activity in maintaining function
000514 Ability to speak with physical
and health
activity
Legend:  Instructed patient and family how 1 2 3 4 5
1 – Severely compromised to perform desired or prescribed
2 – Substantially compromised activity Legend:
3 – Moderately compromised 1 – Severely compromised
4 – Mildly compromised 2 – Substantially compromised
5 – Not compromised NIC 2.2: Exercise Therapy: Joint 3 – Moderately compromised
Mobility 4 – Mildly compromised
5 – Not compromised
 Demonstrated active ROM
exercises
 Performed passive (PROM) or
assisted (AROM) exercises, as
indicated
 Determined limitations of joint
movement and effect on function
 Explained to patient/family the
purpose and plan for joint
exercises
 Encouraged ambulation, if
 appropriate

NOC 3: Fatigue Level NOC 3 : Energy Management

000704 Loss of appetite
1 2 3 4 5  Assessed patient’s physiologic
NOC 3: Fatigue Level
000707 Decreased motivation status for deficits resulting in
000704 Loss of appetite
1 2 3 4 5  fatigue within the context of age 1 2 3 4 5
000708 Headaches and development 000707 Decreased motivation
1 2 3 4 5  Encouraged verbalization of 1 2 3 4 5
000710 Tender lymph nodes feelings about limitations 000708 Headaches
1 2 3 4 5  Determine patient/significant 1 2 3 4 5
000711 Muscles pain other’s perception of causes of 000710 Tender lymph nodes
1 2 3 4 5 fatigue 1 2 3 4 5
000712 Joint Pain  Selected interventions for fatigue 000711 Muscles pain
1 2 3 4 5 reduction using combinations of 1 2 3 4 5
pharmacologic and non- 000712 Joint Pain
pharmocologic categories 1 2 3 4 5
 Determine what and how much
Legend: activity is required to build
1-Severe endurance
2- Substantial  Monitored nutritional intake to Legend:
3- Moderate ensure adequate energy resources 1-Severe
4- Mild  Monitored patient for evidence of 2- Substantial
5- None excess physical and emotional 3- Moderate
fatigue 4- Mild
000715 ADLS  Monitor cardiorespiratory response 5- None
1 2 3 4 5 to activity: tachycardia, other
000729 Rest quality dysrhythmias, dyspnea, 000715 ADLS
1 2 3 4 5 diaphoresis, pallor, hemodynamic 1 2 3 4 5
000721 Balance of activity and rest  pressures, respiratory rate 000729 Rest quality
1 2 3 4 5  Encouraged aerobic workouts as 1 2 3 4 5
000722 Alertness tolerated 000721 Balance of activity and rest
1 2 3 4 5  Monitored and recorded patient’s 1 2 3 4 5
000720 Hematocrit sleep pattern and number of sleep 000722 Alertness
1 2 3 4 5 hours 1 2 3 4 5
 Monitored location and nature of 000720 Hematocrit
Legend: discomfort or pain during 1 2 3 4 5
1 - Severely compromised movement/activity
2 - Substantially compromised  Assisted the patient to understand Legend:
3 - Moderately compromised energy conservation 1 - Severely compromised
4 - Mildly compromised  Assisted the patient in assigning 2 - Substantially compromised
5 - Not compromised priority to activities to 3 - Moderately compromised
 accommodate energy levels 4 - Mildly compromised
 Assisted the patient/significant 5 - Not compromised
other to establish realistic activity
goals
 Assisted the patient to identify
preferences for activity
 Encouraged the patient to choose
activities that gradually build
endurance
 Promoted bedrest/activity
limitation (e.g., increase number of
rest periods) with protected rest
times of choice
 Encouraged alternate rest and
activity periods
 Used passive and/or active range-
of-motion exercises to relieve
 muscle tension
 Encouraged an afternoon nap, if
appropriate
 Avoided care activities during
scheduled rest periods