Rhea Mae V.

Valles
BSN-IV
Pt. L.B. – 19y/o

Assessment Diagnosis Planning Interventions Evaluation

Subjective: Alteration in After 2-4 hrs of Nsg. Action Rationale After 2-4 hrs of
“Sobrang sakit ng comfort nursing interventions 1. Established 1. Building up trust nursing
sikmura ko.” as related to the client will be able rapport. helps Nurse- interventions, goal
verbalized by epigastric to: 2. Observe patient met as evidence
patient. pain as 1. Express nonverbal interaction more by:
manifested reduction of cues/pain effective. 1. Express
Objectives: by facial discomfort behaviors and 2. Observations reduction
 c pain scale grimace and 2. Appear other may be of
of 8,10as muscle relaxed, able objectives congruent with discomfort
the highest guarding to rest defining verbal reports. 2. Appear
and 0 as the appropriately characteristics, 3. Position affects relaxed,
lowest as noted, the patient's able to rest
 c facial especially in ability to sleep appropriate
grimace persons, who effectively. ly.
 c muscle can’t 4. It enhances
guarding communicate. coping abilities.
 V/S taken 3. Assisted 5. Provides relief
as follow: patient to find of discomfort.
T: 36.2 position of
P: 75 comfort.
R: 22 4. Encouraged
BP:120/90 early
ambulation.
5. Administer
prescribed pain
medication.