NCP

NURSING DIAGNOSIS: ACUTE PAIN R/T IRRITATION OF STOMACH LINING AEB ABDOMINAL PAIN SCALE OF 8/10
ASSESSMENT PLAN OF CARE NURSING RATIONALE EVALUATIO

[PLANNING] INTERVENTION N
SUBJECTIVE STG: INDEPENDENT: STG:
:
After 5hrs of  Encourage pt. to  May try to tolerate pain, rather than request After 5hrs of
 Patients SO nursing report pain. analgesic. nursing
reported intervention the pt. intervention,
stabbing or will be able to the pt. reported
cramping pain report pain is  Assess reports of  Changes in pain characteristics may indicate pain is
that started 1 relieved/controlled abdominal cramping spread of disease/ developing complications. relieved.
day prior to . or pain, noting
admission at location, duration,
the right upper intensity 8(0-10
quadrant that LTG: scale). Investigate LTG:
lasted for and report changes
about 3-5 After 2 days of in pain
minutes with a nursing characteristics. After 2 days of
pain scale of intervention, the nursing
8/10, nausea pt. will be able to  May pinpoint precipitating or aggravating intervention,
and vomiting appear relaxed and  Review factors that factors (such as stressful events, food the pt.
prior to able to sleep/rest aggravate or elevate intolerance) or identify developing appeared
admission and appropriately. pain. complication. relaxed and
after able to
admission and sleep/rest
diarrhea (dark  Provided comfort  Promote relaxation, refocuses attention and appropriately.
yellow, easily measures (e.g., may enhance coping abilities.
pass 5-8 backrub, reposition) Goals are
times/day, and diversional partially met.
type 7 stool) activities.
 Permit pt. to assume  Reduces abdominal tension and promotes a

position of comfort, sense of control.
OBJECTIVE: e.g., knees flexed.
 Abdominal  Observe/record  May indicate developing intestinal

pain scale of abdominal obstruction from inflammation.
8/10 in the distention, increased
right upper temperature,
quadrant decreased BP.
 Facial grimace  One can most effectively deal with pain by

 Respond preventing it. Early intervention may
 Weak
Reference: Guidelines for planning and documenting patient care 3rd Edition Marilyn E Doenges, Mary Fances Moorhouse and Alice
C Geissler pg.862 -863
NURSING DIAGNOSIS:IMPAIRED SKIN INTEGRITY R/T DECREASED LEVEL OF ACTIVITY AEB BEDSORES
ASSESSMENT PLAN OF CARE NURSING INTERVENTION RATIONALE EVALUATION
(PAN OF CARE)
SUBJECTIVE: STG: INDEPENDENT STG:
Nagsige rana syag higda  After 5 hrs of  Assess the skin  Establishes  After 5 hrs of
kay kong molihok sya nursing intervention daily. Note baseline with nursing intervention
mosakit man iyang tiyan the pt. will Color ,turgor, which changes the pt.
,dayon wa pd kayo syay demonstrate circulation, in status can demonstrated
gana mokaon maong wa behaviors/technique And sensation. be compared behaviors/technique
pd syay kusog as s to prevent skin Described lesions and s to prevent skin
verbalized by the so breakdown/ and observed appropriate breakdown/
promote healing changes interventions promote healing
OBJECTIVE: instituted
LTG: LTG:
 After 2 days of  Maintain/instruct  Maintaining  After 2 days of
 Facial grimace nursing intervention, in good condition clean dry skin nursing intervention,
 Pt. in bed rest the pt. will be able to skin hygiene , provides a the pt. displayed
 Dry skin and display improvement Wash thoroughly , barrier to improvement in
warm to touch in wound /lesion pat dry carefully , infection. wound /lesion
 Alteration in healing and massage with Patting skin healing
muscle lotion or dry instead of
tone ,muscle appropriate rubbing
cramping,muscl cream reduces risk of
e weakness dermal
 Presence of trauma to dry/
bedsores at his fragile skin.
back Massaging
may increases
V/S taken as circulation to
follow: the skin and
 T-37.4 promotes
 PR-62 BPM comfort.
 RR-21 CPM
 SPO2-98  Reposition  Reduces stress
frequently. Use on pressure
turn sheet as points ,improv
needed. es blood flow
Encourage to tissues, and
periodic weight promotes
shifts. Protect healing.
bony
prominences with
pillows,heel/elbo
w pads
 Skin friction
 Maintain clean, caused by wet
dry, wrinkle-free or wrinkled
linen sheets leads
to irritation
and
potentiates
infection
 Encourage  Decreases
ambulation and pressure on
perform ROM skin from
prolonged bed
rest
 Long /rough
nails increase
 File nails regularly risk of dermal
damage
 May reduce
bacterial
 Cover open contamination
pressure ulcers , promote
with sterile healing
dressing or
protective barrier,
as indicated
 The
DEPENDENT laboratory
 Review the results will
patient’s portray the
laboratory data, internal
as ordered by the conditions
physician. nutritional
status of the
patient such
as the basic
metabolic
panel results
and other
laboratory
data.
 To ensure that
 To regulate IVF the body
Plain Normal receives an
Saline Solution accurate
1L as ordered number of
fluids and
electrolytes.
COLLABORATIVE
 Food is
 Refer to dietetian necessary to
for complete meet the
nutrition increased
assessment and energy
methods on demands
nutritional
support
Reference: Guidelines for planning and documenting patient care 3rd Edition Marilyn E Doenges ,Mary Fances Moorhouse and Alice C
Geissler pg.863-864

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NURSING DIAGNOSIS: ACUTE PAIN R/T IRRITATION OF STOMACH LINING AEB ABDOMINAL PAIN SCALE OF 8/10

ASSESSMENT PLAN OF CARE NURSING RATIONALE EVALUATIO

 Permit pt. to assume  Reduces abdominal tension and promotes a

 Abdominal  Observe/record  May indicate developing intestinal

 Facial grimace  One can most effectively deal with pain by

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