NURSING CARE PLAN
ASSESSMENT NURSING DIAGNOSIS
3. Acute Pain related to
hyperperistalsis, prolonged diarrhea,
skin/ tissue irritation, perirectal
excoriation, fissures as evidenced by
reports of cramping or abdominal
pain, guarding/ distraction behaviors
restlessness.
RATIONALE
Abdominal pain, cramping,
and borborygmi may occur
from gas released from
undigested food, irritation
of bowel mucosa, distention
of the intestines.
REF.: Medical & Surgical interventions have been characteristics. (Be very sensitive
Nursing Textbook by
Black & Hawks
pp. 809 - 810 Vol. I
2. Report pain is relieved
OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION
Gen. Objective: Independent:
Relieve/ Reduce/ 1. Encourage patient/ child to May try to tolerate pain rather
Eliminate pain. report pain. than seek treatments.
2. Assess reports of abdominal Changes in pain characteristics
cramping or pain, noting location may indicate spread of disease/
Specific Objectives: duration, intensity,. Investigate and developing complications.
After the nursing report changes in pain Child's primary way ofconveying
pain is maybe thru crying.
employed, with the childs mov't or actions
the child will be able to: e.g. crying as this suggests pain
1. Appear relax and be or something irritating to the child).
able to sleep or rest 3. Note nonverbal cues, e.g. Body language/ non verbal cues
appropriately. restlessness, reluctance to move, may be both physiological and
abdominal guarding. psychological and maybe used in
controlled. Investigate dispcrepancies between conjunction with verbal cues to
verbal and nonverbal cues. determine extent/ severity of the
problem.
4. Review factors that aggravate May pinpoint precipitating or
or alleviate pain. aggravating factors ( such as
stressful events, food
intolerance), or identify developing
complications.
5. Encourage patient to assume Reduces abdominal tension,
position of comfort, and promotes sense of control.
e.g. knees flexed as assisted by
the mother.
6. Provide comfort measures Promotes relaxation, refocuses
and diversional activities ( repositionattention, and may enhance coping
play with the child, offer toy) abilities. Promotes nurse - child
relationship.
7. Cleanse rectal area with mild soapProtecting skin from bowel acids,
and water/ wipes after each stool & preventing excoriation.
 provide skin care. (Seek assistance from mother)
con.t
8. Observe/ record abdominal May indicate developing intestinal
distention, increased temperature, obstruction from inflammation,
. edema and scarring.
Collaborative:
1. Implement prescribed dietary Complete bowel rest can reduce
modification. pain, cramping.
2. Administer medications as
indicated:
Analgesics: For pain management,
Anticholinergics; relieve spasmsof Gi tract &
Antipyretics. lowers body temp. due to fever.
 Patient is in NPO. 3. Imbalanced nutrition: less than
But could be given by body requirements realted to
cotton water. inability to ingest/ digest food or
absorb nutrients; N & V, NPO
O: Patient is weak, status & nasogastric suctioning &
restless, pallor, loss of appetite as evidenced by
showing expressions reported inadequate food intake
of difficulty with her less than RDA, lack of interest in
situation. food "waray gana pagkaon,"/
aversion to eating & perceived
inability to digest food.
4. RISK for infection related to
inadequately primary defenses
(weak body), altered peristalsis,
change in pH secretions,
nutritional deficiencies & stasis of
body fluids; chronic diseases,
Food and water intake is
very essential since we can't
survive without the two.
Gradual decrease of food
intake would lead to body
failure.
Body weakness would
further lead to infections.
3. Patient will be able to 1. Assess the over all nutritional To determine any deviation form
demonstrate progress- status of the client by checking her previous data.
ive weight gain toward daily weights, tissue integrity
goal with normalization & presence of adequate body fat
of laboratory values; and muscle mass.
Demonstrate behaviors, 2. Encourage client to choose To stimulate appetite.
lifestyle changes to foods that are appealing.
regain and or maintain 3. Avoid foods that causes So as not to cause intestinal
appropriate weight. intolerances/ gastric motility problems.
(gas - forming foods, hot & spicy)
4. Limit fiber/ bulk. Since they can lead to early
satiety.
5. Promote pleasant, relaxing To stimulate proper appetite/
environment. enhance intake.
6. Limiting fluids hours prior to So as not to cause early
meal satiety.
7. Weigh weekly & prn. To monitor effectiveness of
care.
DISCHARGE PLANNING:
1. Emphasize importance of well
balance, nutritious intake.
2. Provide info regarding
individual needs & ways to meet
these needs within financial
constraints.
4. Achieve timely 1. Demonstrate lifestyle changes For personal growth of the
healing. Be free of signs to promote safe environment. person.
of infection 2. Cleanse insertion sites daily & To prevent sepsis.
Be afebrile. prn with solution.
3. Encourage early ambulation, For mobilization of gastric
deep breathing, coughing, secretions.
position changes.
DISCHARGE PLANNING:
1. Explain the importance of proper
 hygiene especially hand washing.

5. Ineffective breathing pattern Normal range of value for 5. The client will maintain 1. Maintain calm attitude, while To as to maintain and improve
O: RR 30 bpm. related to abdominal pain/ RR is 15 - 20 bpm. an effective breathing dealing with client to limit anxiety. rapport.
Patient having deep,tenderness as evidenced by RR 30 pattern as evidenced by 2. Assist client in use of relaxation So as to relax the client from
shallow, irregular bpm, anxiety/ decreased energy, RR within normal limits, techniques. the tension and anxiety she is
breathing. fatigue. relaxed respiratory effort suffering.
Demonstrate approp.
coping behaviors.
S: Patient uttered, 6. Anxiety related to change in Anxiety is a vague feeling 6. The client will express 1. Assess the client's level of To determine what interventions
"Tangala na ini na health status, change in of apprehension as to what and demonstrate anxiety by listening and observing. are suitable for the client.
adi tak may irong." environment, fear of pain returning will happen next. It is a normal decreasing 2. Reassure the client and To let the client feel secured,
& irritation brought about by the defense mechanism of the manifestations of acknowledge that the unknown is that she is not alone.
O: Fatigue, touchi NGT tube attached. body. anxiety as evidenced of frightening.
the NGT tube which displaying behavior 3. Allow significant others to
she wants to be associated with remain with the client.
removed. relaxation.

NAME: ROOM & BED #:

AGE/SEX: WARD:
CHIEF COMPLAINT: ATTENDING PHYSICIAN:

Prepared by: Submitted to:

DONN ED MARTIN A. ABRIL MR. ROBERT PONTIAN AGNER, R.N.

RTRMF - CN Student Nurse Clinical Instructor
EVRMC
15-Nov-05