N Cholangitis 3j3y4a

NURSING CARE PLAN CUES

NURSING DIAGNOSIS

Subjective: The patient verbalized: “Masakit tiyan ko”

Acute pain related to spasms and abdominal pain.

Objective Observed evidence of pain Guarding behavior Frequently changing position to avoid pain Irritability Facial grimace

ANALYSIS

GOAL & OBJECTIVES

Cholangitis is the most serious complicatio n of gallstones and more difficult to diagnose. It is caused by impacted stone in the common bowel duct, resulting in bile stasis, bacteremia and septicemia if left untreated. It is more ikely to occur when an already infected

Goal: After 3 hours of nursing interventions the client will be free from experiencing pain in the abdomen.

INTERVENTION

RATIONALE

__Met __Partially met __Unmet

Objectives: 1. After 40 minutes of assessment, the client will be able to describe the characteristic, onset, location, duration, severity, and precipitating factors of pain.

EVALUATION

>Assess the client of pain to include the characteristic, onset, location, duration, severity, and precipitating factors of pain.

2. After 15 minutes >Assess for the of assessing for presence of fear or the presence of anxiety. fear or anxiety, the client will be able to verbalize if she’s feeling

>Pain is a subjective experience and must be described by the patient in order to plan effective treatment. (http://wps.prenhall. com/wps/media/obje cts/3918/4012970/N ursingTools/ch46_NC P_AcutePain)

>Fear and anxiety can alleviate client’s perception of pain. (http://bja.oxfordjour nals.org/content/87/ 1/144.full)

bile duct becomes obstructed. Patients having cholangitis is suffering from severe abdominal pain.

anxious.

3. After 15 minutes >Assess causes of of assessing for possible discomfort. client’s discomfort, client will verbalize the cause of discomort.

(All-in-one Care Planning Resource by Swearinge n; page 453)

> Discomfort can be caused or aggravated by presence of nonpatent indwelling catheters causing bladder pain, NG tube resulting in gastric fluid and gas accumulation, or parenteral lines that have infiltrated IV fluids or medications. (Nursing Care Plans by Doenges, 8th ed; page 798)

4. After 10 minutes of monitoring the patient for pain, the client will be able to verbalize the rate of pain she is experiencing.

>Monitor patient for pain or other discomfort. Devise a pain scale with patient, rating discomfort on a scale of 0 (no pain) to 10 (worst pain)

5. After 30 minutes > Encourage use of of deep breathing relaxation techniques

>Enables more precise measurement of discomfort and relief obtained. (All-in-one Care Planning Resource by Swearingen; page 454)

> Relieves muscle and emotional

exercise and doing the bent-knee position, the client will be able to verbalize that the abdominal tension will be relieved/reduced.

such as deepbreathing exercises.

tension; enhances sense of control and may improve coping abilities.

>Position the client in a bent-knee position.

>This position decreases tension on abdominal contents to promote comfort. (All-in-one Care Planning Resource by Swearingen; page 454)

6. 30 minutes after >ister istering analgesics as analgesics, client prescribed. will report reduced abdominal pain.

>Nonsteroidal antiinflammantory drugs (NSAIDs) or opioid analgesics may be indicated, depending on severity of the pain. For the postoperative patient, continuous IV of opioid analgesics are used with increasing frequency and efficacy. (All-in-one Care

Planning Resource by Swearingen; page 455)

7. After 40 minutes of nursing interventions the client will be able to verbalize willingness to alleviate pain.

> Note client’s attitude towards pain and use of pain medications. > Evaluate client’s response to analgesics and assist in transitioning or altering drug regimen, based on individual needs and protocols.

>To promote wellness