Patients Name: M.F.B.

Medical Diagnosis: T/c Cholelithiasis hydrops NURSING CARE PLAN ASSESSMENT Subjective: DIAGNOSIS Acute pain related to obstruction/ductal spasm, inflammatory process on the abdomen area as evidenced by verbal reports, guarding or distraction behaviors. PLANNING Short term goal: INTERVENTION Independent: Observe and document location of pain, severity (0-10), and character of pain. Assist in differentiating cause of pain and provides information about disease progression, development of complications and effectiveness of intervention. Bed rest in low fowlers position reduces intra abdominal pressure. Promotes rest redirects attention, may enhance coping. RATIONALE EVALUATION Short term goal met: After 1 hour of nursing intervention the pain felt by the patient is controlled and rates it as 5/10.

Masakit kasi yung tiyan ko. as verbalized by the client. Objective: Guarding behavior Distraction behavior Pain Scale: 7/10

After 1 hour of nursing intervention, the pain felt by the patient will be relieved or controlled by means of: 1. Properly positioning the client. 2. Providing use of relaxation techniques.

Promote bed rest, and in low fowlers position. Encourage use of relaxation technique like listening to the radio.

Long term goal: After 8 hours of nursing intervention, the pain felt by the patient will be controlled or relieved.

Long term goal met: After 8 hours of nursing intervention, the pain felt by the patient is controlled and rates it as 2/10.

Collaborative: Administer medication prescribed by the doctor. To relieve abdominal pain.

Patients Name: M.F.B. Medical Diagnosis: T/c Cholelithiasis hydrops