Nursing Care Plan For Choledocholithiasis

NURSING CARE PLAN ASSESSMENT SUBJECTIVE: “Masakit ung tiyan ko” as verbalized by the patient OBJECTIVE: >Abdominal distention >Pain scale: 10 (highest) >(-)flatulence >(-)bowel movement >(+) guarding behavior >V/S taken as follows: BP: 110/70 RR: 20 PR:79 Temp: 37.0 oC

NURSING DIAGNOSIS Acute pain related to inflammation and distortion of tissues and ductal spasm.

INFERENCE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

supersaturation of cholesterol in the bile

Short term goal: After 1 hour of nursing intervention the pain felt by patient will be alleviated, from pain scale of 10 it will be reduced to 3.

INDEPENDENT >Provide comfort measures such as: - touch therapy - repositioning - use of heat/cold compression

>to promote nonpharmacological pain management.

After 1 hour of nursing intervention the pain felt by patient will be alleviated, from pain scale of 10 it will be reduced to 3.

>Instruct use of relaxation techniques such as: - deep breathing exercises - guided imagery

>to distract attention from pain and to reduce tension.

inflammation of the gall bladder precipitates bile causing formation of gallstones obstruction in the common bile duct pressure obstruction ductal spasms inflammation of common bile duct pain

>Instruct client to report pain as soon as it begins. COLLABORATIVE: Administer pain reliever as ordered by the physician

>timely intervention is more likely to be successful in alleviating pain >to alleviate pain

ASSESSMENT Subjective: “Minsan lng ako dumumi sa isang linggo” Objective: > on liquid diet >Abdominal distention >(-)flatulence >(-)bowel movement >(-)bowel sounds

NURSING DIAGNOSIS Constipation related to decrease peristalsis guarded by the disease.

INFERENCE Specific disease Slowed muscle contraction of the colon Stool move through the colon to slowly Constipation

PLANNING Short term goal: After 8 hours of nursing interventions, the patient will be able to eliminate stool which are soft semi formed consistency Long term goals: After 3 days of continuous rendering of nursing interventions, the patient will be able to establish normal patterns of bowel functioning as evidenced by intestinal motility

INTERVENTION Independent: >monitor intake and output (I & O) >Advise patient to turn from side to side Collaborative: >Administer stool softeners or laxatives (lactulose)as ordered by the physician. Monitor its effectiveness

RATIONALE >to aid in identifying dietary deficiencies >movement enhances intestinal motility >it facilitates defecation

EVALUATION Short term goal: After 8 hours of nursing interventions, the patient will be able to eliminate stool which are soft semi formed consistency Long term goals: After 3 days of continuous rendering of nursing interventions, the patient will be able to establish normal patterns of bowel functioning as evidenced by intestinal motility