Jean Paola M. Nolasco Bsn004- Group 15 Nursing Care Plan

Jean Paola M. Nolasco BSN004- GROUP 15 Nursing Care Plan

Cues

Nursing Diagnosis

Analysis and Interpretation

Alteration in comfort related to inflammator y process

Cholecystitis with cholelithiasis is an acute or chronic inflammation of the gallbladder associated with obstruction by gallstone(s) of the cystic or common bile ducts. Stones are made up of cholesterol, calcium billirubinate or a mixture caused by changes in the bile composition. Cholecystitis, an acute complication of cholelithiasis, is an acute infection of the bladder. acute pain comes from the chemical irritation of the peritoneum and is a part of the inflammatory process.

Subjective Cues: - “lagi akong nahihilo, sumasakit ang ulo ko tapos nagsusuka” - “sobrang sakit ng tyan ko, sa banding kanan hanggang likod ko sumasakit” - “ matagal bago mawala yung sakit, minsan umaabot ng limang oras, mawawala tapos babalik din, madalas sa gabi nagsisimula” - pain scale : 9 (pain scale: 1-10, 10 being the most painful) Objective Cues: - abdominal distension - tachycardia, diaphoresis - hypoactive bowel sounds - (+) guarding bahavior

Source: Handbook for the Textbook of Medical-Surgical Nursing, 11th edition by

Goals and Objectives Goal: After 4 hours of nursing interventions, the client will report that pain is controlled and lessened. The pain will decrease from 9 to 4 based on the pain scale.

Interventions

Rationale

Objectives: After nursing interventions, the client will be able to:

Evaluation

After nursing interventions, the client was able to: Supplemental

1. Have a baseline data about her current status

1. Observe and document location, severity (0-10 scale), and character of pain. (e.g., steady, intermittent or colicky)

1. Assists in differentiating cause of pain. and provides information about disease progression/resolution, development of complications, and effectiveness of interventions.

1.have a baseline data about her current status

2. Report response to medication.

2. Note response to medication, and report to physician if pain is not being relieved.

2. Severe pain not relieved by routine measures may indicate developing complications/ need for further interventions.

2. voice out if the pain is relieved by medication or not.

3. have increased comfort.

3.1 Promote bed rest, allowing client to assume position of comfort.

3. Bed rest, in semi-fowler’s position reduces intra-abdominal pressure; however, client will naturally assume least painful position.

3. voice out feelings of comfort and decreased painful sensations.

3.2 Use soft/cotton linens,

3.2 Reduce irritation/dryness of