Student Nurse: Patient Name: Diagnosis: Assessment S- Masakit tyan ko mula pa kagabi grabe hindi ako makatulog -pain

scale of 8/10 O- (+) facial grimace (+) guarding behavior -(+)body weakness -(+)abdominal distension Diagnosis Acute pain possibly related to upper gastrointestinal bleeding Scientific Explanation The patient is experiencing pain on his abdominal area probably due to ulcers, hyper acidity or bleeding in the epigastric area Planning After 8 hours of nursing interventions, the patient will be report reduced pain and discomfort Selected Interventions Independent > Assess conditions contributing to long-term pain > Note availability of SO Implemented Interventions Independent > Assessed conditions contributing to long-term pain > Noted availability of SO Rationale Evaluation Goal not met. Patient reported no reduction of pain and pain scale remained at 8/10.

> To identify contributing factors to long-term pain > To ensure continuity of interventions

> Note age and > Noted age and > To determine gender of the gender of the the perceptive patient patient ability of the patient > Evaluate pain > Evaluated behaviors pain behaviors > To identify the patients responses to pain

> Assess degree > Assessed of degree of maladjustment maladjustment

> To determine factors contributing to increased pain

> Encourage compliance to therapeutic interventions > Reduce anxiety and stress

> Encouraged compliance to therapeutic interventions > Reduced anxiety and stress

> To alleviate episodes of pain

> To ensure proper compliance to interventions

> Include patient and SO in making the plan of care > Observe for any untoward signs and symptoms > Encourage adequate rest periods Dependent > Apply pain management interventions, as indicated

> Included patient and SO in making the plan of care > Observed for any untoward signs and symptoms > Encouraged adequate rest periods

> To limit focus on pain

> To determine presence of a new physical problem

> To help alleviate pain

Dependent > Applied pain > To relieve management acute interventions, as manifestations indicated of the disease

process > Administer pain medications, as ordered > Administered pain > To alleviate medications, as episodes of pain ordered