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Medical Diagnosis: Acute Gastroenteritis (Adult)

Problem: Acute Pain RT Inflammatory Process

Assessment Nursing Diagnosis Scientific

Explanation

Planning Interventions Rationale Evaluation

Subjective:

Masakit ing atyan

ku as verbalized by

the patient

Objectives:

The patient

manifested:

Abdominal Pain Appears weak Limited range of

motion

Restlessness Verbalization of

pain with a pain

scale of 6/10.

The pt. may

manifest:

Facial grimaces Irritability Impaired thought

process

Reducedinteraction with

people

sleepdisturbances

diaphoresis

Acute Pain related to

Inflammatory Process

Gastroenteritis is the

inflammation of the

stomach and

intestinal tract thatprimarily affects the

small bowel. One of

the manifestations of

gastroenteritis is

abdominal pain.

During the course of

inflammation, the

bodys immune

response, causing the

release of cytokine

and prostaglandincausing an increase in

vascular permeability

and causes pain,

which felt by the

patient in the

abdomen. (Joyce M.

Black, 2008)

Short term:

After 3 hrs of nursing

interventions the pt.

will report pain isrelieved from a pain

scale of 6/10 to 2/10.

Long Term:

After 2 days of

nursing interventions

the pt will be free

from pain as

evidence bydemonstration of

relaxation skills and

diversional activities

with the help of the

SO.

1. Establish rapport2. Monitor and

record vital signs.

3.

Review factorthat aggravate or

alleviate pain

4. Instruct the SO tomassage the area

where pain is

elicited if not

contraindicated

5. Encourage painreduction

techniques

6. Provide adequaterest

7. Providediversional

activities like

socialization

8. Administeranalgesics to

maintain

acceptable level

of pain if notcontraindicated

9. Instruct client toperform deep

breathing

exercises (DBE)

10.Monitoreffectiveness of

1. To gain the trustand cooperation

of the patient

2.

To providebaseline data and

note deviations

from normal.

3. Helpful inestablishing

diagnosis and

treatment needs

4. Tolessen/alleviate

pain caused by

various factors(administer meds

via IV push)

5. To reduce painand promote

relief/comfort

6. To promotehealing

7. For clientscomfort and

relief from pain8. To decrease pain.9. Deep breathing

exercises may

reduce pain

sensation/ used

in pain

Short term:

After 3 hrs of nursing

interventions the pt.

shall have reportedpain is relived from a

pain scale of 6/10 to

2/10

Long Term:

After 2 days of

nursing interventions

the patient shall be

free from pain as

evidenced bydemonstration of

relaxation skills and

diversional activities

with the help of the

SO.

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pain medications management

10.To promotetimely

intervention/

revision of plan

of care