NURSING DIAGNOSIS

 Acute pain related to inflammation, edema, distention of the pancreas, and peritoneal
irritation
 Ineffective breathing pattern related to severe pain, pulmonary infiltrates, pleural
effusion, atelectasis, and elevated diaphragm
 Imbalanced nutrition, less than body requirements, related to reduced food intake and
increased metabolic demands
 Impaired skin integrity related to poor nutritional status, bed rest, multiple drains, and
surgical wound

GOALS
 Relief of pain and discomfort
 Improved respiratory function
 Improved nutritional status
 Maintenance of skin integrity
 Prevent complications

NURSING CARE PLAN

Nursing Goal and Nursing

Diagnosis Analysis Objectives Interventio Rationale Evaluation
ns
-Acute pain -Because the Goal: By The client
related to pathologic December reports relief
inflammation process 18, 2008, the of pain and
, edema, responsible for client will discomfort.
distention of pain is report relief -Uses
the pancreas, autoindigestio of pain and analgesics and
and n of the discomfort. anticholinergic
peritoneal pancreas the s as prescribed
irritation objective is to Objectives: without
relieve pain After all the -with held -decrease overuse.
and decrease nursing oral feedings the -Maintains
pancreatic interventions formation of bedrest as
enzymes. , the client secretin prescribed
will be able -the patient -Avoids
to report is maintained -to restore alcohol to
relief of pain on parenteral and maintain decrease
from pain fluids and fluid balance abdominal
scale of 9 to electrolytes pain.
6.
-Nasogastric
suction -to relieve
n/v or to
treat
abdominal
distention
and paralytic
-frequent oral ileus
hygiene and
care -to decrease
 discomfort
from the
nasogastric
tube and to
relieve
dryness of
-Maintain bed the mouth
rest
-to decrease
the
metabolic
reate and
reduce the
secretion of
pancreatic
and gastric
-If enzymes
experiencing
severe pain, -the client
report to may be
physician experiencing
hemorrhage
of the
pancreas or
the dose of
the
 analgesics
may be
-provide inadequate
frequent and
repeated but -The patient
simple often has
explanations clouded
about the sensorium
need for because of
withholding severe pain,
fluids, fluid &
maintenance electrolyte
of gastric disturbances,
suction, and and hypoxia.
bed rest.