NURSING CARE PLAN

CUES
NURSING
DIAGNOSIS
ANALYSIS GOAL & OBJECTIVES INTERVENTION RATIONALE EVALUATION

Subjective:
The patient
verbalized:
Masakit tiyan
ko

Objective
Observed
evidence of
pain
Guarding
behavior
Frequently
changing
position to
avoid pain
Irritability
Facial grimace


Acute pain
related to
spasms and
abdominal
pain.

Cholangitis
is the most
serious
complicatio
n of
gallstones
and more
difficult to
diagnose. It
is caused
by
impacted
stone in
the
common
bowel
duct,
resulting in
bile stasis,
bacteremia
and
septicemia
if left
untreated.
It is more
ikely to
occur when
an already
infected

Goal: After 3 hours of nursing
interventions the client will be
free from experiencing pain in
the abdomen.

Objectives:

1. After 40 minutes
of assessment, the
client will be able
to describe the
characteristic,
onset, location,
duration, severity,
and precipitating
factors of pain.






2. After 15 minutes
of assessing for
the presence of
fear or anxiety,
the client will be
able to verbalize if
shes feeling








>Assess the client of
pain to include the
characteristic, onset,
location, duration,
severity, and
precipitating factors
of pain.








>Assess for the
presence of fear or
anxiety.












>Pain is a subjective
experience and must
be described by the
patient in order to
plan effective
treatment.

(http://wps.prenhall.
com/wps/media/obje
cts/3918/4012970/N
ursingTools/ch46_NC
P_AcutePain)



>Fear and anxiety
can alleviate clients
perception of pain.

(http://bja.oxfordjour
nals.org/content/87/
1/144.full)

__Met
__Partially met
__Unmet
bile duct
becomes
obstructed.
Patients
having
cholangitis
is suffering
from
severe
abdominal
pain.

(All-in-one
Care
Planning
Resource
by
Swearinge
n; page
453)
anxious.


3. After 15 minutes
of assessing for
clients
discomfort, client
will verbalize the
cause of
discomort.











4. After 10 minutes
of monitoring the
patient for pain,
the client will be
able to verbalize
the rate of pain
she is
experiencing.



5. After 30 minutes
of deep breathing



>Assess causes of
possible discomfort.
















>Monitor patient for
pain or other
discomfort. Devise a
pain scale with
patient, rating
discomfort on a scale
of 0 (no pain) to 10
(worst pain)



> Encourage use of
relaxation techniques



> Discomfort can be
caused or aggravated
by presence of
nonpatent indwelling
catheters causing
bladder pain, NG
tube resulting in
gastric fluid and gas
accumulation, or
parenteral lines that
have infiltrated IV
fluids or medications.

(Nursing Care Plans
by Doenges, 8
th
ed;
page 798)


>Enables more
precise measurement
of discomfort and
relief obtained.

(All-in-one Care
Planning Resource by
Swearingen; page
454)


> Relieves muscle
and emotional
exercise and doing
the bent-knee
position, the client
will be able to
verbalize that the
abdominal tension
will be
relieved/reduced.










6. 30 minutes after
administering
analgesics, client
will report
reduced
abdominal pain.










such as deep-
breathing exercises.




>Position the client in
a bent-knee position.










>Administer
analgesics as
prescribed.













tension; enhances
sense of control and
may improve coping
abilities.


>This position
decreases tension on
abdominal contents
to promote comfort.

(All-in-one Care
Planning Resource by
Swearingen; page
454)



>Nonsteroidal
antiinflammantory
drugs (NSAIDs) or
opioid analgesics
may be indicated,
depending on
severity of the pain.
For the postoperative
patient, continuous
IV of opioid
analgesics are used
with increasing
frequency and
efficacy.

(All-in-one Care





7. After 40 minutes
of nursing
interventions the
client will be able
to verbalize
willingness to
alleviate pain.









> Note clients
attitude towards pain
and use of pain
medications.

> Evaluate clients
response to
analgesics and assist
in transitioning or
altering drug
regimen, based on
individual needs and
protocols.


Planning Resource by
Swearingen; page
455)


>To promote
wellness