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    Acute Pain

    Uploaded by

    Sofronio Omboy
    This nursing document outlines a care plan for a patient experiencing abdominal pain and decreased fluid volume. The plan includes monitoring vital signs and intake/output, administering pain medication, encouraging small frequent meals and proper positioning, and providing comfort measures. The goal is to alleviate the patient's pain and restore proper fluid balance.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Acute Pain

    Uploaded by

    Sofronio Omboy
    22 views6 pages
    This nursing document outlines a care plan for a patient experiencing abdominal pain and decreased fluid volume. The plan includes monitoring vital signs and intake/output, administering pain medication, encouraging small frequent meals and proper positioning, and providing comfort measures. The goal is to alleviate the patient's pain and restore proper fluid balance.

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    © © All Rights Reserved

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    This nursing document outlines a care plan for a patient experiencing abdominal pain and decreased fluid volume. The plan includes monitoring vital signs and intake/output, administering pain medication, encouraging small frequent meals and proper positioning, and providing comfort measures. The goal is to alleviate the patient's pain and restore proper fluid balance.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    22 views6 pages

    Acute Pain

    Uploaded by

    Sofronio Omboy
    This nursing document outlines a care plan for a patient experiencing abdominal pain and decreased fluid volume. The plan includes monitoring vital signs and intake/output, administering pain medication, encouraging small frequent meals and proper positioning, and providing comfort measures. The goal is to alleviate the patient's pain and restore proper fluid balance.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    You are on page 1of 6

    Name of Patient Age/Gender: Ward: Room no:

    Chief Complaint: Physician  


    Diagnosis:

    Date/ Cues N Nursing Diagnosis Patient Outcome Nursing Interventions Implementations


    Time e
    e
    d
    Deficient Fluid Volume Within 1-2 hours of nursing  Measure intake 1
    J S: “ Kanina pa ako related to active fluid intervention the client will be and output q 4°.
    A dumudumi ng P volume loss. manifesting alleviation of Record and report
    malambot na significant
    N H pain as evidence by;
    malambot.” changes. Include
    U Y urine, and stools.
    A S R: Tachycardia,
    R O: I a. report reduce pain dypnea, or
    Y ( + ) sunken eyeballs. from scale of 8/10 hypotension may
    ( + ) poor skin turgor.
    C
    Rationale: indicate fluid
    Pain scale of 8/10 A to 0-1 out of 10
    2 Volume depletion, or volume deficit or
    V/S as follows: L extracellular fluid (ECF) electrolyte 2
    5 BP: 170/100mmHg
    volume contraction, b. display increase in imbalance.
    PR: 82 bpm appetite  Monitor and record
    2 RR: 40 bpm, and
    C occurs as a result of loss
    vital signs q 2° or
    0 T: 36.7°C O of total body sodium. as often as
    2 M Causes include vomiting, c. exhibit relax facial necessary until
    1 F excessive sweating, expression and stable. Then
    3
    O diarrhea, burns, diuretic able to rest monitor and record
    use, and kidney failure. vital signs q 4°.
    7:00 R comfortably
    Clinical features include R: Tachycardia,
    AM T dyspnea, or
    diminished skin turgor,
    hypotension may
    dry mucous membranes, indicate fluid
    tachycardia, and volume deficit or 4
    orthostatic hypotension. electrolyte
    imbalance.
     Assess skin turgor
    and oral mucous
    membranes q 4°.
    R: to check for
    dehydration
     Encourage
    patient to have
    small frequent
    meals
     R:
    5

    Assess factors that


    aggravate pain
    Rationale: Helpful in
    establishing diagnosis
    and interventions
    needed

    Administer pain
    medication as ordered 8
    by the physician.
    Rationale: to relieve the
    pain

    Assess 30 minutes after


    giving medication
    Rationale: to check for 9
    effectiveness and if pain
    is reduced

    Advise patient to
    position self in semi-
    fowlers or any position
    that provide comfort 10
    Rationale: Positioning
    the self reduces
    abdominal tension and
    promotes sense of
    control.

    Instruct patient to do
    deep breathing exercise
    Rationale: Deep
    breathing facilitate
    expansion of the
    abdomen. Thus, help
    lessen the pain

    Provide comfort
    measures like back rub,
    reposition, clean and
    quite environment.
    Rationale: To promote
    relaxation and allow
    patient to rest

    Provide diversional
    activities such as
    reading, watching tv,
    and/or playing board
    games
    Rationale: This would
    help patient refocus or
    divert its attention to
    other things

    Monitor Vital Signs


    noting tachycardia,
    increased in respirations
    and hypertension
    Rationale: Changes in
    these may indicate
    acute pain or discomfort

    Encourage patient to
    have small frequent
    meals
    Rationale: Help reduce
    stomach distention and
    pain after eating

    Instruct patient when


    allowed to eat to start
    with liquids then
    progress to bland foods
    like crackers, bananas,
    toast, etc. and avoid
    caffeine, alcohol, tea.
    Rationale: It would
    allow bowel or intestinal
    tract to rest and adjust
    that could help reduce
    pain/cramping.

    Reference:
    Vera, M. (2020). Acute
    Pain Nursing Care Plan.
    Retrieved January 27,
    2021 from
    https://nurseslabs.
    com/7-inflammatory-
    bowel-disease-nursing-
    care-plans/4/

    Bitram, T. (2017). The


    14 foods to eat when
    you have stomachache.
    Retrieved January 25,
    2021 from
    https://www.insider.com/
    What-to-eat-when-you-
    have-a-stomachache-
    20178

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