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NURSING CARE PLAN

ASSESSMENT NURSING INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION


DIAGNOSIS
SUBJECTIVE: Acute pain supersaturation Short term INDEPENDENT >to promote After 1 hour of
“Masakit ung related to of cholesterol in goal: >Provide comfort non- nursing
tiyan ko” as inflammation and the bile After 1 hour of measures such pharmacological intervention
verbalized by distortion of nursing as: pain the pain felt by
the patient tissues and inflammation of intervention the - touch therapy management. patient will be
ductal spasm. the gall bladder pain felt by - repositioning alleviated,
OBJECTIVE: patient will be - use of heat/cold from pain scale
>Abdominal alleviated, from compression of 10 it will be
distention precipitates bile pain scale of 10 reduced to 3.
>Pain scale: 10 causing it will be >Instruct use of >to distract
(highest) formation of reduced to 3. relaxation attention from
>(-)flatulence gallstones techniques such pain and to
>(-)bowel as: reduce tension.
movement - deep breathing
>(+) guarding obstruction in exercises
behavior the common - guided imagery
>V/S taken as bile duct >timely
follows: >Instruct client to intervention is
BP: 110/70 pressure report pain as more likely to be
RR: 20 obstruction soon as it begins. successful in
PR:79 alleviating pain
Temp: 37.0 oC ductal spasms COLLABORATIVE:
Administer pain >to alleviate
inflammation of reliever as pain
common bile ordered by the
duct physician

pain
ASSESSMENT NURSING INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Constipation Specific disease Short term Independent: Short term
“Minsan lng ako related to goal: >monitor intake >to aid in goal:
dumumi sa decrease After 8 hours of and output (I & O) identifying After 8 hours of
isang linggo” peristalsis Slowed muscle nursing dietary nursing
guarded by the contraction of interventions, >Advise patient deficiencies interventions,
Objective: disease. the colon the patient will to turn from the patient will
> on liquid diet be able to side to side >movement be able to
>Abdominal eliminate stool enhances eliminate stool
distention Stool move which are soft intestinal which are soft
>(-)flatulence through the semi formed Collaborative: motility semi formed
>(-)bowel colon to slowly consistency >Administer stool consistency
movement softeners or
>(-)bowel Long term laxatives >it facilitates Long term
sounds Constipation goals: (lactulose)as defecation goals:
After 3 days of ordered by the After 3 days of
continuous physician. Monitor continuous
rendering of its effectiveness rendering of
nursing nursing
interventions, interventions,
the patient will the patient will
be able to be able to
establish normal establish
patterns of normal
bowel patterns of
functioning as bowel
evidenced by functioning as
intestinal evidenced by
motility intestinal
motility