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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Acute pain related After 30 (1hr) minutes DEPENDENT: Goal met.
The patient to gastric lining of nursing  Administer prescribed  To alleviate pain
complained of irritation as interventions, the analgesics as ordered and promote patient After 30 (1hr) minutes of
burning and evidenced by comfort.
patient will be able to: nursing interventions, the
gnawing epigastric verbalization of (anong analgesics ba? Ang
pain "nararamdan pain and guarding patient was able to:
alam ko is omeprazole e)
ko na nuon, pero behavior in pain.  To identify changes
hindi ko na Short-Term Goal: INDEPENDENT: in the patient’s Patient was able to report a
pinapansin at (paki-tanggal na  The patient will be condition and pain level of 3 or less within
umiinom ako ng yung naka- able to report a  Monitor vital signs response to pain 24 hours. And the patient
gamot, pero masakit highlight)/ regularly. management was able to demonstrate
pain level of 3/10
parin” as verbalized interventions. relief from pain through
or less within 24 decrease guarding behavior
by the patient. (after ilang hours pwede mag
hours. VS?) in pain.
(yung verbalization  The patient will be  It helps to reduce
dapat ang sinasabi able to pressure on the
is tungkol duon sa demonstrate relief stomach and may (if dalawa ang planning,
pain for example alleviate discomfort. dalawa rin dapat ang
from pain through
“parang may acid  To promote evaluation)
decrease
sa tiyan ko…”) relaxation and
guarding behavior
reduces muscle
OBJECTIVE: in pain.
tension, aiding in
pain management.
Pain scale: 7/10 (paki-tanggal na yung  For early detection
Blood Pressure: naka-highlight)/ of complications is
140/80 mmHg  Elevate the head of the crucial for prompt
Pulse Rate: 93 bpm bed or provide a intervention.
Respiratory Rate: comfortable position for
20 cpm the patient.
Temperature: 36 C  Addressing the root
Oxygen Saturation:  Encourage relaxation cause contributes to
99 techniques. effective pain
management.
(paki-tanggal na (what relaxation techniques)
yung naka-
highlight)/
 Assess and monitor for
signs of complications.

(instruct the client to avoid spicy


and harsh food)

(instruct the client to eat slowly)

COLLABORATIVE:

 Collaborate with the


healthcare team to
address the underlying
cause of epigastric pain.

(palitan ng “dietician meal plan)

Sequence dapat ay
Independent
Dependent
Collab

Paki-ayos ang formatting and alignment ng letters

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