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NCP-Acute Pain

The patient presented with acute stomach pain rated at 8/10. The nursing assessment found the patient had a facial grimace, was crying, exhibited abdominal guarding and body weakness. The nursing diagnosis was acute pain related to irritation in the gastric mucosa. The plan was for the patient to verbalize a reduced pain scale, demonstrate relaxation skills and diversional activities after 2 hours of nursing interventions. Interventions included establishing rapport, assessing pain using PQRST, vital signs and knowledge/preferences. Comfort measures, relaxation techniques, quiet environment and limiting irritating foods/beverages were also planned. Small, frequent feed

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Matt Reyes Del Castillo
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333 views2 pages

NCP-Acute Pain

The patient presented with acute stomach pain rated at 8/10. The nursing assessment found the patient had a facial grimace, was crying, exhibited abdominal guarding and body weakness. The nursing diagnosis was acute pain related to irritation in the gastric mucosa. The plan was for the patient to verbalize a reduced pain scale, demonstrate relaxation skills and diversional activities after 2 hours of nursing interventions. Interventions included establishing rapport, assessing pain using PQRST, vital signs and knowledge/preferences. Comfort measures, relaxation techniques, quiet environment and limiting irritating foods/beverages were also planned. Small, frequent feed

Uploaded by

Matt Reyes Del Castillo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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NURSING CARE PLAN

Chief Complain: Stomach Pain

ASSESSMENT NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION


DIAGNOSIS

S: “Sumasakit na yong Acute Pain Related to After 2 hours of Independent Goal Met, after 2 hours of
tyan niya kaninang hapon irritation in gastric nursing nursing intervention patients
Establish Rapport To promote patient
at di na din siya mucosa as evidence by intervention the pain scale reduce to 3/10
cooperation
makakain, tapos kaninang complain of pain with a patient will: from 8/10, patients also
hapunan humigop ng scale of 8/10, facial These data can be used demonstrate relaxation skill
 Verbalize pain Assess the pain
sabaw ng sinigangkaso grimace, body to identify the extent of and diversional activities.
relief from characteristics
lalo daw sumakit ung weakness, and pain as well as serve as
pain scale of (PQRST) and obtains
tyan niya” as verbalized abdominal guarding baseline data
8/10 to 3/10 vital signs
by the mother. behavior.

O:  Demonstrate
Facilitates Relaxation, to
use of Assess patient
-RR: 22 distracts attention and
relaxation skill knowledge and
reduce tension.
-Facial Grimace and preference for the
diversional pain-relief strategies.
-Crying
activities. (Promote relaxation
-Abdominal Guarding techniques such as
Behavior  Follow deep breathing
prescribed technique)
-Body Weakness pharmacologic
-Pain scale of 8/10 al regimen Help to decrease the
Provide comfort by anxiety of the patient
assisting the client in and it helps to reduce
a comfortable the pain
position

Promotes rest and


Provide quite enhances coping skills
environment and
reduce stress stimuli

Divert the patient


Teach the client
attention from pain
diversional activities

This is to prevent
Encourage Clients to
further inflammation
avoid foods and
and irritation to gastric
beverage that irritate
mucosa
the stomach.

Small frequent feedings


Encourage small
prevent distention and
frequent feedings
gastric release

Dependent:
relieves painful
Administer stomach cramps
medications as
ordered

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