ASSESSMENT ANALYSIS PLANNING INTERVENTION RATIONALE EVALUATION

“Masaki tang tiyan Acute pain r/t At the end of 1 a.) Positioned the To provide comfort to
kop o” as verbalized traumatized hour, the patient patient at a comfortable the patient.
by the patient tissues will be able to: manner. Goal Met

• report relief
of pain To provide optimal skin
Objective: b.) Instructed the S.O to care The patient
• report bathed the patient. was able to
• Crying comfort repot relief of
pain and
• Facial increase in
grimace c.) Instructed the S.O of comfort
noted the patient to take To replace fluid loss
liquids frequently at 2 –
• Hands on the 3 glasses of water a
abdomen day.
• Guarded
behavior
d.) Keep fluids within
• P/S - 5/10 the patient’s reach.
For easy access of fluid
intake.

e.) Give the patient full

liquid diet in small
feedings. To provide nutrients.

f.) Instructed the S.O to

provide safety
To prevent injuries
measures when the
patient is nauseated.
g.) Monitored and
record vital signs.

h.) Administered Serve as basis in the

medications as ordered development of the
by the physician. patient.

For easy recovery of

the patient.

• Assessed level
of pain, location
and • For baseline
characteristics data

• Encouraged
verbalization of
needs
• To assist or
• Observed verbal monitor client’s
and non-verbal condition
cues
• Incongruence of
cues indicates
• Provided further
comfort assessment
measures such • To provide non-
as back rub, and pharmacologic
 hot compress pain
management
• Provided calm
environment

• Encouraged • To reduce
deep breathing fatigue
exercises

• Encouraged
diversional • To promote
activities such comfort
as talking to
S.O. and texting
• To reduce
• Suggested S.O.
fatigue
to be at bedside

• Administered
medications –
NUBAIN

• Watched out
episodes of pain • To comfort the
and child

• Promoted rest • Acts as a pain

reliver

• To medicate
prophylactially as
 appropriate

• To prevent
fatigue
ASSESSMENT ANALYSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: altered nutrition: At the end of the a.) Instructed the To provide patient
less than body shift, the patient will S.O of the patient to easily digested Goal met
requirements be able tolerate provide diet snacks. The patient was
related to regular diet with modification as able tolerate regular
- “Hindi na siya
decreased in adequate nutrients. indicated such as diet with adequate
masyadong
appetite secondary small feedings with nutrients.
kumakain” as
to acute snacks.
verbalized by the
gastroenteritis.
S.O of the patient.

b.) Instructed the

S.O to give
OBJECTIVE:
adequate fluids at 2
–3 glasses of To avoid fluid loss
water/day. or dehydration
- poor appetite

- irritable
c.) Instructed the
- choosy in S.O to provide
selecting foo breast milk to the
patient.
- inability to ingest
foods
To provide nutrients
to the patient
d.) Promote
pleasant a relaxing
env’t as possible by
removing
unnecessary
materials.
To provide comfort
 to the patient.

e.) Use flavoring

agents such as
vanilla and lemon
extracts.

To stimulate the
f.) Avoid foods that appetite of the
cause intolerances patient.
such as gas forming
foods like
chicharon.

g.) Limit intake of To prevent further

fiber diet such as complications
banana, cereals.

h.) Instructed the

S.O to encourage
the patient to
choose foods that
appealing to her.
 to avoid satiety

.) Monitored vital
signs and recorded.

j.) Administered
medication as To stimulate
ordered by the appetite
physician.

Serve as basis in
the development
of the patient.

For easy recovery

of the patient.