Professional Documents
Culture Documents
Subjective:
Gasinakit akon nga
tiyan as verbalized
by the patient.
Objective :
Pain scale of
10
Splinting of
the
abdomen
Facial
grimace
noted
Weak
Pale
V/S
Temp.- 36c / ax.
CR- 136 bpm
RR- 29 bpm
Wt.- 25 kg.
Nursing
Diagnosis
Acute pain
related to
enlargement
of the liver .
Objectives
Intervention
To facilitate
the
maintenance
of regulatory
mechanism
and functions.
Independent:
Assess pain
characteristics
(quality,
severity,
location,
onset,
duration,
precipitating
and relieving
factors).
Specific
objective:
After 1 hour
of nursing
intervention
the patient
will:
-Verbalize
relief from
pain and rate
it as 3/10
from 10/10.
-Absence of
facial grimace
- displays
good skin
turgor.
monitor signs
and symptoms
associated
with pain, such
as BP, heart
rate,
temperature,
color and
moisture
of skin, restless
ness, and
ability to focus.
Assess
patients
willingness or
ability to
explore a
range
of techniques
aimed at
controlling
pain.
Rationale
Goal met.
These data
can be
used to
identify the
extent of the
pain serve as
baseline
information.
Some people
deny the
experience of
pain when it
is
present. Atte
ntion
to associated
signs may
help the
nurse in
evaluating
pain.
Anticipate
need for pain
relief.
Evaluation
Respond
immediately
to complaint
of pain.
One can
most effectively
After 3 hours
of nursing
intervention
the patient
will verbalize
relief from
pain and rate
it as 3/10
from 10/10.
Assessment
Nursing
Diagnosis
Planning
Intervention
Rationale
Evaluation
According to Mrs. last January 08, 2013 her son was suffering constipation. Because of financial
incapacity they do not go directly to the hospital or even in clinic for consultation instead, they
dependently use over- the- counter medication/herbal medication to relieve the condition of her son.
They gave him papaya for the thought that he will relieve on it but after 4 days the child was not able to
defecate so they decide to bring him to the hospital (DRSTMH) for consultation in the OPD ward. His
diagnoses were constipation and undergo some laboratory test. The doctor decides to admit S.E for
proper monitoring of his condition. The day of admission, January 12, 2013 the doctor finds out in the
laboratory result of low haemoglobin level the following diagnosis to consider cardiomegaly, to consider
hepatomegaly and to consider pleural effusion so the doctor decides to admit him for proper monitoring
of his condition. As we interview Mrs. She verbalized that only S.E from the member of their family
encountered the condition like this.