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    College of Health Sciences: Urdaneta City University

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    Dan Dan Manaois
    The nursing care plan addresses a patient experiencing acute abdominal pain likely due to cholelithiasis. The plan includes (1) assessing the patient's pain level and characteristics, intake/output, and vital signs; (2) setting a short-term goal of relieving pain within 8 hours through nursing interventions and a long-term goal of pain relief over 3 days; and (3) implementing interventions like medication administration, environmental controls, education, and active/passive activities to reduce pain and promote recovery.

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    College of Health Sciences: Urdaneta City University

    Uploaded by

    Dan Dan Manaois
    2K views2 pages
    The nursing care plan addresses a patient experiencing acute abdominal pain likely due to cholelithiasis. The plan includes (1) assessing the patient's pain level and characteristics, intake/output, and vital signs; (2) setting a short-term goal of relieving pain within 8 hours through nursing interventions and a long-term goal of pain relief over 3 days; and (3) implementing interventions like medication administration, environmental controls, education, and active/passive activities to reduce pain and promote recovery.

    Original Description:

    ncp

    Original Title

    Alipio.epigastric pain-NCP

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    The nursing care plan addresses a patient experiencing acute abdominal pain likely due to cholelithiasis. The plan includes (1) assessing the patient's pain level and characteristics, intake/output, and vital signs; (2) setting a short-term goal of relieving pain within 8 hours through nursing interventions and a long-term goal of pain relief over 3 days; and (3) implementing interventions like medication administration, environmental controls, education, and active/passive activities to reduce pain and promote recovery.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    2K views2 pages

    College of Health Sciences: Urdaneta City University

    Uploaded by

    Dan Dan Manaois
    The nursing care plan addresses a patient experiencing acute abdominal pain likely due to cholelithiasis. The plan includes (1) assessing the patient's pain level and characteristics, intake/output, and vital signs; (2) setting a short-term goal of relieving pain within 8 hours through nursing interventions and a long-term goal of pain relief over 3 days; and (3) implementing interventions like medication administration, environmental controls, education, and active/passive activities to reduce pain and promote recovery.

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    URDANETA CITY UNIVERSITY

    San Vicente West, Urdaneta City, Pangasinan 2428

    COLLEGE OF HEALTH SCIENCES


    Bachelor of Science in Nursing

    NURSING CARE PLAN (NCP)


    Name of Student: Manaois, Darlene Dana S. Year Level and Group: BSN-3/4A

    Affiliating Agency/Area: Month/Year of Exposure:

    Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation


    (at least 10)

    Subjective: Problem, Etiology, Signs Short Term Goal: Independent: Short Term Goal Evaluation
    (P.E.S.) format S.M.A.R.T. + Evidence
    “Sobrang sakit ng  Observe and document  Provides information about After 8 hours of nursing intervention
    bandang ibaba ng Acute pan related to After 8 hours of nursing location of the pain, scale disease progression. the patient pain was relieved or
    tyan ko” as verbalized abdominal condition intervention the patient pain (0-10) and character of the Development of controlled
    by the patient (probably cholelithiasis) as will be relieved or controlled pain complications and GOALS MET
    evidence by positive facial effectiveness of intervention
    grimace narrowed focus
    garding behavior  Maintain a calm and quite  To minimize stimulus that
    environment could aggravate the condition
    of the patient
    Objective: INFERENCE Long Term Goal: Long term Goal Evaluation
    (at least 5) Scientific Explanation S.M.A.R.T.+ Evidence
     (+) Facial (Diagram Form)  Note for the location, scale,  To determine the nursing At the end of the 3 days of
    grimacing Fatty food After 3 days of nursing intensity and onset of pain care to be given to the patient rendering nursing care, the patient
     (+) Cholesterol intervention the client will: was relieved from pain
     Measure intake and output  Low urine output and high
    Abdominal
     patient was relieve q 4°.Record and report specific gravity indicates GOAL MET
    guarding hypovolemia
    from pain significant changes. Include
    behavior
    urine, and stools.
     (+) Restless Increase phospholipids in
    and irritable bile Educative
     (-) Bowel  Encourage use of relaxation  To promote rest redirect
    sound technique attention. May enhance
     Pain scale of coping
    8/10
     Vs as follow:  Promote bed rest  To reduces intra-abdominal
    Crystallizes and form nidus pressure
     RR: 24 bpm
     PR: 105 bpm
     Encourage dimensional  To distract attention and
     TEMP: 38.5C activities and relaxation reduce tension
     \BP: 105/65 techniques such as focused
    mm Hg breathing and imaging
    Stone forms
    Therapeutic
     Reduce or eliminate factors  Personal factors can
    that precipitate or increase influence pain and pain
    of patient’s pain experience tolerance. Factors that may
    Impaired gallbladder (e.g., fear, fatigue, be precipitating or
    motility monotony, and lack of augmenting pain should be
    knowledge). reduced or eliminated to
    enhance the overall pain
    management program.

     To minimize dermal
    Epigastric Pain  Control environmental discomfort
    pressure

    Dependent  To reduce severe pain/


     Administer medication as Promotes rest and relaxes
    indicated such as smooth muscle
    anticholinergic. Sedatives
    narcotic

    Checked by: _________________________________ Date: ____________________


    Clinical Instructor’s Name and Signature

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