NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE CUES: Acute Pain related to Within 8 hours of nursing INDEPENDENT: After 8 hours of nursing
“I don't have an infection in biological injuring interventions, the patient 1. Obtain the patient’s and - To fully understand the patient’s interventions, the patient
my gallbladder which is agents: obstruction will be able to: significant other’s assessment of pain symptoms. was able to:
good, but I do feel the and inflammatory pain including the location,
pain,” as verbalized by the process,   Report that pain is characteristics, onset, duration,  Report that pain is
patient. relieved and/or frequency, quality, aggravating relieved and/or
controlled. factors, and relieving factors. controlled with
OBJECTIVE CUES:  Demonstrate the use patient verbalizing
 Facial expression of pain of relaxation skills and 2. Determine the patient’s pain - To better comprehend certain that, “I feel better
 Hands are shaking diversional activities intensity through the use of a pain aspects of the patient’s pain and now, the pain is
 Guarding behavior indicated for pain. scale. have an objective data as a basis gone.”
 Self-focusing for the plan of care.  Demonstrate the use
 V/S are as follows: of relaxation skills and
 Temp: 36.7 °C 3. Monitor skin color, temperature, - These are usually altered in acute diversional activities
 PR: 120 bpm and vital signs such as heart rate, pain. indicated for pain.
 RR: 18 cpm blood pressure, respirations.
 BP: 130/90 mmHg
4. Make time to listen to and - To help alleviate anxiety and GOAL MET
maintain frequent contact with refocus attention which can relieve
patient. pain.

5. Promote bedrest for patient, - Bedrest in low-Fowler’s position

allowing them to assume position reduces intra-abdominal pressure.
of comfort. However, patient will naturally
assume least painful position.

6. Encourage the use of relaxation - To promote rest, redirect

techniques. Provide diversional attention, and enhance coping. The
activities. Include significant inclusion of significant others helps
others in the process. in assisting the patient in doing
these activities.

- To provide comfort by altering

7. Provide cognitive-behavioral psychological responses to pain.
 therapy (CBT) for pain
management.
- To remove gastric secretions that
8. Maintain NPO status, insert stimulate the release of
and/or maintain nasogastric cholecystokinin and gallbladder
suction as indicated. contractions.

DEPENDENT: - To help alleviate pain through

9. Administer medication as pharmacological means if non-
indicated. Teach patient and pharmacological measures are not
significant others about the effective. Clients and significant
medication to be taken. others should be taught about all
aspects of the medications that
they are taking to promote
understanding and adherence to
medication.

COLLABORATIVE: - The surgical team is a unit

10. Refer the patient to the members providing the continuum of care
of the surgical team for surgery. beginning with preoperative care,
and extending through
perioperative (during the surgery)
procedures, and postoperative
recovery.

References:

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2018). Nurse's pocket guide: Diagnoses, prioritized interventions, and rationales. FA Davis.

Vera, M. (2019, April 10). 4 Cholecystitis and Cholelithiasis Nursing Care Plans. Nurseslabs. Retrieved from https://nurseslabs.com/4-cholecystitis-cholelithiasis-nursing-care-plans/2/