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    NCP Proper Acute Pain

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    Edgar Garcia
    The patient presented with right upper quadrant abdominal pain rated at 7/10, caused by gallbladder stones as revealed by ultrasound. Vital signs were stable. The pain was characterized as cramping and non-radiating. Goals were to relieve pain and provide comfort. Interventions included assessing pain and vital signs, allowing comfortable positioning, rest, deep breathing exercises, and diversional activities. The short term goal of decreasing pain to 4/10 within 30 minutes was met.

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    NCP Proper Acute Pain

    Uploaded by

    Edgar Garcia
    470 views1 page
    The patient presented with right upper quadrant abdominal pain rated at 7/10, caused by gallbladder stones as revealed by ultrasound. Vital signs were stable. The pain was characterized as cramping and non-radiating. Goals were to relieve pain and provide comfort. Interventions included assessing pain and vital signs, allowing comfortable positioning, rest, deep breathing exercises, and diversional activities. The short term goal of decreasing pain to 4/10 within 30 minutes was met.

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    ncp pain chole

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    ncp proper acute pain

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    The patient presented with right upper quadrant abdominal pain rated at 7/10, caused by gallbladder stones as revealed by ultrasound. Vital signs were stable. The pain was characterized as cramping and non-radiating. Goals were to relieve pain and provide comfort. Interventions included assessing pain and vital signs, allowing comfortable positioning, rest, deep breathing exercises, and diversional activities. The short term goal of decreasing pain to 4/10 within 30 minutes was met.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    470 views1 page

    NCP Proper Acute Pain

    Uploaded by

    Edgar Garcia
    The patient presented with right upper quadrant abdominal pain rated at 7/10, caused by gallbladder stones as revealed by ultrasound. Vital signs were stable. The pain was characterized as cramping and non-radiating. Goals were to relieve pain and provide comfort. Interventions included assessing pain and vital signs, allowing comfortable positioning, rest, deep breathing exercises, and diversional activities. The short term goal of decreasing pain to 4/10 within 30 minutes was met.

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    of 1

    Assessment

    S> Masakit dito (pointing to RUQ of abdomen). Para syang nagagasgas, lalo na pag gumagalaw ako. Di naman maiwasang gumalaw kase madami din ginagawa. O> Vital signs are as follows: T: 36.5c per right axilla, BP: 120/80 mmHg per right arm ---o, RR: 18 cpm, PR: 82 bpm per left radial pulse, +2; Pain rated as 7/10 characterized as cramping, non-radiating, continuous pain; Seen holding RUQ of abdomen noted, grimacing, weakness noted, Capillary refill of 1-2 seconds, ultrasound reveals stone formation and deposition in the gall bladder. A> Acute pain related to stimulation of the nerve endings.

    Explanation of the Problem


    Patient came to Emergency Room from OPD, due to Right Upper Quadrant pain. The pain is mainly due to the gall bladder stones that was irritating the patients gallbladder. (as revealed by the Ultrasound). Because of the gallbladder stones, the cell membrane of the gallbladder starts to be disrupted. Causing the release of inflammatory response to the blood stream. Chemical mediators such as Histamine, Prostaglandin, Bradyikinins, and Leukotrienes cause the swelling of the gallbladder. Prostaglandin and Bradykinins were responsible for the cramping pain on RUQ of the abdomen being felt by the patient. In addition, cholecystectomy is indicated for the management of this disease problem.

    Goals and Objectives


    Goal: To deliver maximum care and treatment to this client with gall bladder stones and to relieve from any kind of discomfort. LTO: Within 3 days of nursing interventions, patient will continuously manifest relief of pain and no complaints of any kind of discomfort. STO: After 30 minutes of nursing interventions, the client will manifest a decrease of pain from 7/10 to 4/10. : After 5 minutes of nursing education, the client will be able to do Deep Breathing Exercises. : After 10 minutes of nursing discussion, the client will be able to enumerate as many as possible stimuli causing pain. : After 5 minutes of nursing interventions, the client will be able to assume comfortable position to decrease discomfort.

    Interventions

    Rationale
    to detect patient response to the condition. BP may aggravate from intense pain. RR, may came from intense pain may lead to hyperventilation, PR compensation of the body to pain sensation, T may indicate infection or disease process. 2. Characteristic of pain indicates what specific organ problem is being encountered. Can be used to properly manage the problem. 3. Non-verbal cues of pain gives you a clue or hint regarding the pain status of the client. 4. Vital signs are affected by pain sensation thus, PR and RR which are responsible for proper oxygenation of the cells. Must be check to see if proper distribution of nutrients and o2 occurs. 5. Patient knows better her body, thus, allowing her to assume her comfortable position may help to alleviate the pain sensation thus promoting comfort in patients condition. 6. Sleep could be a good example of diversion activity to relieve pain due to non-responding to pain sensation by closing the gateway of impulses to the brain. In addition, rest and sleep, rehydrates and energizes the cells. 7. DBE can help relieve pain by allowing the release of bte endorphins which is well known as our natural analgesic. 8. Diversional activity closes the gateway of pain nerve impulses, thus it wont reach the pain center of the brain producing NO pain sensation or atleast, drcreased.

    Evaluation
    STO: After 30 minutes of nursing interventions, the client able to manifest a decrease of pain from 7/10 to 4/10. Fully met : After 5 minutes of nursing education, the client was able to do Deep Breathing Exercises. Fully met : After 10 minutes of nursing discussion, the client was able to enumerate as many as possible stimuli causing pain. Fully met : After 5 minutes of nursing interventions, the client was able to assume comfortable position to decrease discomfort. Fully met LTO: Within 3 days of nursing interventions, patient will continuously manifest relief of pain and no complaints of any kind of discomfort. * Fully met, if the patient will be able to verbalize no complain of pain. ** Partially met, if patient verbalize at least a decreased in pain sensation. Modify intervention or Continue. ***Unmet, if still the patient complains of intense pain. Continue or modify Interventions.

    1. Assess Vital signs. 1. 1. Vital signs could be a great trick

    2. Assess PQRST of 2. pain. 3. Assess non-verbal3. cues of pain. 4. Assess capillary refill. 4.

    5. Allow patient to 5. assume comfortable position. 6. Promote rest and 6. sleep by clustering interventions.

    7. Instruct to do Deep Breathing 7. Exercises. 8. Advice to do 8. diversional activities such as reading books.

    Page 3 of 3 NURSING CARE PLAN PROPER

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