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ASSESSMENT EXPLANATION OF THE OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

PROBLEM
S Epigastric pain occur with Goal: Patient will have a Dx Short term goal fully met if
“Nahihilo po ako na conditions that cause safe termination of Assess pain characteristics >These data can be used after 2 hours of nursing
parang nasusuka tapos inflammation of the pregnancy. (quality, severity, location, to identify the extent of interventions the patient
minsan po masakit po digestive organs, such as Short term goal: onset, duration, the pain as well as serve as will verbalize relief from
tiyan ko ,lalo napo pag gastritis and pancreatitis. After 2 hours of nursing precipitating and relieving a baseline information. pain and rate it as 2/10
kakatapos kop o kumain” Pregnant women may interventions the patient factors). from 7/10.
O experience epigastric pain will verbalize relief from Short term partially met if
-BP 170/100 due to increased pain and rate it as 1/10 Observe or monitor signs >Some people deny the After 2 hours of nursing
-PR 95 abdominal pressure and from 7/10 and symptoms associated experience of pain when it interventions the patient
-Restless hormonal changes that Long term goal: with pain such as BP, Heart is present. Attention to will verbalize relief from
-Pacing slow the digestive process. After 16 hours of nursing rate, Temperature, color associated signs may help pain and rate it as 5/10
-Weak in appearance intervention client will and moisture of skin, the nurse in evaluating from 7/10.
-Pale skin in appearance exhibit increased comfort restlessness and ability to pain. Short term goal not met if
with bilateral pedal edema such as baseline levels for focus. the After 2 hours of
-Rigid abdomen HR, BP, and respirations nursing interventions the
-Rated pain as 7/10 in a and relaxed muscle tone Assess for probable cause >Different etiological patient will verbalize relief
scale of 0/10 for body posture. of pain. factors respond better to from pain and rate it as
different therapies. 7/10 from 7/10.
Tx Long term goal fully met if
NSG DIAGNOSIS: Altered Did as much care as >- To avoid disturbances After the16 hours of
comfort related to possible without waking during sleep, and to nursing intervention client
abdominal pain the client, and did as much maximize sleeping will exhibit increased
care as possible while the process. comfort such as baseline
patient is still awake. levels for HR, BP, and
respirations and relaxed
Administered pain meds. >To relieve discomfort and muscle tone for body
take maximum effects of posture.
sedatives. Long term goal partially
met if After the 16 hours
Observed and obtained >To determine usual sleep of nursing intervention
feedback from clients pattern and provide client will exhibit increased
regarding usual bedtime, appropriate intervention comfort such as baseline
routines, # of hours of levels for respirations and
sleep, and environmental relaxed muscle tone for
needs. body posture only.
Long term goal not met if
Edx After the 16 hours of
Encourage the use of >Nonpharmacological nursing intervention if the
nonpharmacological pain relaxation techniques will client didn’t exhibit
relief measures such as decrease the production of increased comfort such as
guided imagery, music gastric acid, which in turn baseline levels for HR, BP,
therapy and acupressure, will reduce pain. and respirations and
etc. relaxed muscle tone for
body posture.
Instruct the client to avoid >These medication may
NSAIDs such as aspirin. cause irritation of the
gastric mucosa.

Instruct the client that >An irregular schedule of


meal should be eaten at meals may interfere with
regular paced intervals in a the regular administration
relaxed setting. of medications.

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