ncp ca
Content
Assessment
Subjective: “medyo masakit yung tyan ko” the client verbalized.” Objective: Abdominal pain Rated pain as 6/10. 1 being the lowest and 10 being the highest.
Nursing Diagnosis
Acute pain related to ductal spasm secondary to biliary duct obstruction
Analysis
Cholangitis is the infection with the bile duct caused by bacteria. It tends to occur if the bile duct is partially obstructed by gallstone. A person with cholangitis may complain with abdominal pain (particularly in right upper quadrant of the abdomen).
Goals and Objectives
Goal After 2 hours of nursing intervention the client will verbalize minimal feeling of pain. Objectves: After 2 hours of nursing intervention the client will
Intervention
Rationale
Evaluation
Independent: - Monitor vital signs - To monitor any changes from the previous data.
Verbalizes methods that provides relief
- Determin e pathophysi ological cause of pain
- To determine precipitatin g factor
- Accept client’s description of pain
-
Pain is a
Demonstrate us of relaxation skills and diversional activities.
subjective experience and cannot be felt by others. - Provide comfort measures such as touch, quiet environme nt and calm activities - Encourag e adequate rest periods
- To promote nonpharma cologic pain manageme nt.
Will follow prescribed pharmacologi cal regimen.
Dependent: - Administ er analgesics - To prevent fatigue
- Collabora te in treatment in underlying condition
- To maintain acceptable level of pain.
Subjective: “medyo masakit yung tyan ko” the client verbalized.” Objective: Abdominal pain Rated pain as 6/10. 1 being the lowest and 10 being the highest.
Nursing Diagnosis
Acute pain related to ductal spasm secondary to biliary duct obstruction
Analysis
Cholangitis is the infection with the bile duct caused by bacteria. It tends to occur if the bile duct is partially obstructed by gallstone. A person with cholangitis may complain with abdominal pain (particularly in right upper quadrant of the abdomen).
Goals and Objectives
Goal After 2 hours of nursing intervention the client will verbalize minimal feeling of pain. Objectves: After 2 hours of nursing intervention the client will
Intervention
Rationale
Evaluation
Independent: - Monitor vital signs - To monitor any changes from the previous data.
Verbalizes methods that provides relief
- Determin e pathophysi ological cause of pain
- To determine precipitatin g factor
- Accept client’s description of pain
-
Pain is a
Demonstrate us of relaxation skills and diversional activities.
subjective experience and cannot be felt by others. - Provide comfort measures such as touch, quiet environme nt and calm activities - Encourag e adequate rest periods
- To promote nonpharma cologic pain manageme nt.
Will follow prescribed pharmacologi cal regimen.
Dependent: - Administ er analgesics - To prevent fatigue
- Collabora te in treatment in underlying condition
- To maintain acceptable level of pain.
