NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Independent:
Subjective: • Acute pain • Cholelithiasis is • After 8 hours • Observe and • Assist in • After 8
related to the formation of of nursing document differentiating hours of
“Masakit ang inflammation interventions location of pain, cause of pain nursing
gallstones,
tagiliran ko” as and distortion , the patient severity (0-10 and provides intervention
verbalized by of tissues.
which are pain will be scale), and information s, the
patient. composed of relieved or character of pain. about disease patient pain
cholesterol, controlled. progression, was relieved
Objective: calcium salts, development of or
and bile complications controlled.
• Facial mask pigments. and
of pain. When effectiveness of
gallstones intervention.
• Guarding block the flow • Promote bed rest, • Bed rest in low
behavior. of bile, the and in low fowler’s position
gallbladder fowler’s position. reduces intra
• Self becomes abdominal
foucusing. pressure.
swollen,
• Use soft cotton • Reduces
• V/S taken as
leading to the linens, calamine irritation,
follows: possibility of lotion, oil bath dryness of the
pain, and cool or moist skin and itching
T: 37.3 inflammation, compress as sensation.
P: 80 or infection. indicated.
R: 18 The signs and • Control • Cool
Bp: 110/90 symptoms of environmental surroundings
cholelithiasis temperature. aid in
often do not minimizing
begin until the dermal
discomfort.
gallstone
• Encourage use of • Promotes rest,
causes
relaxation redirects
blockage in the technique. attention, may
biliary system. enhance
They may coping.
include,
abdominal
pain, usually in
the upper right Collaborative:
quadrant of the Administer
abdomen, medication as
jaundice, fever. prescribed:
Tests and • Anticholinergics. • Relieves reflex
spasm or
procedures that
smooth muscle
can detect contraction and
cholelithiasis assist with pain
include x-rays, management.
CT scan, • Narcotics • Given to reduce
ultrasound, severe pain.
ERCP, and a
cholecystogra
m.