GENERAL SANTOS DOCTORS’ MEDICAL SCHOOL FOUNDATION INC.

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS OBJECTIVES NURSING RATIONALE EVALUATION

INTERVENTIONS
Subjective cues: Goal: Independent:
- Complained - Acute pain related to Long term: - Assess pain -These data can -After nursing
about upper upper abdominal pain. -After 2 days of characteristics(quality, be used to identify interventions
abdominal pain. Interference: nursing severity, location, the extent of pain patient verbalizes
- Pain Scale 10/10 - Acute pain, which intervention the onset, duration, as well as serve relief in pain and
- Described the usually occurs in patient will relieving factors). as baseline progresses
pain as: sharp, response to tissue verbalize relief information. relaxation.
pressing, pulling, injury, results from from pain. - Observe or monitor -Goal partially
activation of
spreading, Short term: signs and symptoms -Attention to met.
peripheral pain receptor
drawing, tight, s and their specific A
- After an hour of associated with associated signs
nauseating, delta and C sensory relaxation, patient pain,such as BP, may help the
fearful, nerve fibers will be alleviated heart rate, nurse in
unbearable (nociceptors). from pain. temperature,color and evaluating the
Chronic pain related to moisture ofskin, pain.
Objective cues: ongoing tissue injury is restlessness and
- Facial grimace presumably caused by ability to focus. -Reduces
- Guarding persistent activation of Collaborative: abdominal tension
- Irritable these fibers. - Encourage patient to and promotes
- Crying assume position of sense of control.
comfort. (e.g. knees
flexed) -Aids in relaxing
the abdominal
-Place a pillow under muscles
the knees

-Advice the patient to -This help to ease

perform deep pain, and promote
breathing exercise comfort.