ASSESSMENT Subjective: Nasakit unay ti tiyan ko, lalu nu kalkalpas ko mangan.

Objective: Restless Pacing Rigid abdomen Selffocused Wrinkled nose Raised upper lips Rapid breathing Rated pain as 7/10 in a pain scale of 010

DIAGNOSIS Acute pain related to chemical burn of gastric mucosa

PLANNING After 2 hours of nursing interventions, the patient will verbalize relief from pain and rate it as 2/10 from 7/10.

INTERVENTION Independent: Assess pain characteristics (quality, severity, location, onset, duration, precipitating and relieving factors). Observe or monitor signs and symptoms associated with pain, such as BP, heart rate, temperature, color and moisture of skin, restlessness, and ability to focus. Assess for probable cause of pain.

RATIONALE

EVALUATION Goal met. After 2 hours of nursing interventions, the patient verbalized relief from pain and rated it as 2/10 from 7/10.

These data can be used to identify the extent of the pain as well as serve as a baseline information.

Some people deny the experience of pain when it is present. Attention to associated signs may help the nurse in evaluating pain.

Assess patients knowledge of or preference for the array of pain-relief strategies available.

Different etiological factors respond better to different therapies.

Some patients may be unaware of the effectiveness of nonpharmacological methods and may be

BAUTISTA, Jesther Rowen, SN IV

Assess patients willingness or ability to explore a range of techniques aimed at controlling pain.

willing to try them, either with or instead of traditional analgesic medications. Often a combination of therapies (e.g., mild analgesics with distraction or heat) may prove most effective.

Anticipate need for pain relief.

Some patients will feel uncomfortable exploring alternative methods of pain relief. However, patients need to be informed that there are multiple ways to manage pain.

Respond immediately to complaint of pain.

One can most effectively deal with pain by preventing it. Early intervention may decrease the total amount of analgesic required.

BAUTISTA, Jesther Rowen, SN IV

Eliminate additional stressors or sources of discomfort whenever possible.

Encourage small, frequent meals

In the midst of painful experiences a patients perception of time may become distorted. Prompt responses to complaints may result in decreased anxiety in the patient. Demonstrated concern for patients welfare and comfort fosters the development of a trusting relationship.

Identify and limit foods that cause discomfort such as spicy foods and carbonated drinks. Encourage to assume position of comfort.

Patients may experience an exaggeration in pain or a decreased ability to tolerate painful stimuli if environmental, intrapersonal, or intrapsychic factors are further stressing them.

Dependent: Administer analgesic for relief of pain (e.g. morphine sulfate).

Small meals prevent distention and gastrin release.

BAUTISTA, Jesther Rowen, SN IV

Administer antacids (e.g. Magnesium Hydroxide Aluminum Hydroxide)

Food has acid neutralizing effect and dilutes gastric content.

Collaborative: Provide and implement prescribed dietary modifications.

Reduces abdominal tension and promotes sense of control.

Relieves abdominal pain by reducing the peristaltic activity.

Helps relieve pain by neutralizing stomach acid and increasing bicarbonate and mucus secretion.

Patient may receive nothing by mouth initially. When oral intake is allowed, food choices will depend on BAUTISTA, Jesther Rowen, SN IV

the diagnosis.

BAUTISTA, Jesther Rowen, SN IV