Professional Documents
Culture Documents
SUBJECTIVE:
Napakasakit ng
tiyan ko (Im
having severe
stomach pain) as
verbalized by the
patient.
OBJECTIVE:
Abdominal
guarding
Rigid body
posture
Facial
grimacing
V/S taken as
follows
T: 37.3C
P: 89
R: 19
BP: 110/ 80
DIAGNOSIS
Acute or
chronic pain
maybe related
to chemical
burn of gastric
mucosa, oral
cavity and
physical
response such
as flex muscle
spasm in the
stomach wall.
INFERENCE
PLANNING
After 4 hours of
nursing
interventions, the
Patient verbalize
relief of pain and
demonstrate
relaxed body
posture and be
able to sleep or
rest properly.
INTERVENTION
Independent
Note reports of
pain, including
location, duration,
and intensity (0-10
scale).
Note nonverbal
pain cues.
Provide small
frequent meals.
Provide frequent
oral care and
comfort measures
including back rub
and position
change.
RATIONALE
EVALUATION
After 4 hours of
nursing
interventions, the
Patient was able to
verbalize relief of
pain and
demonstrate relaxed
body posture and be
able to sleep or rest
properly.
Helpful in
establishing
diagnosis and
treatment needs.
Non-verbal cues
may be both
physiological and
psychological and
may be use in
conjunction with
verbal cues to
evaluate extent
and severity of
the problem.
Food has an acidneutralizing effect
and dilutes the
gastric contents.
Collaborative
Provide and
implement dietary
modifications.
Administer
medications as
indicated such as
analgesics.
Small meals
prevent distention
and the release of
gastrin.
Specific foods that
cause distress
vary among
individuals. Spicy
foods, alcohol,
and coffee can
precipitate
dyspepsia.
Reduces joint
stiffness,
minimizing pain
and discomfort.
Halitosis from
stagnant oral
secretions is
unappetizing and
can aggravate
nausea.
Client may receive
nothing by mouth
initially. When
oral intake is
allowed, food
choices depend
on the diagnosis
and etiology of
the bleeding.