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    Nursing Care Plan ER

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    Ma Theresa Medrocillo
    In liver cirrhosis, abdominal pain may be present because of recent, rapid enlargement of the liver, producing tension on the fibrous covering of the liver (Glisson's capsule) abdominal distention, caused by ascites, can cause compression of surrounding organs and overexpansion of the surrounding skin causing stimulation of pain receptors. At the end of my 3 (r) Assessment days span provides of care information my about the patient cause of pain.

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    Nursing Care Plan ER

    Uploaded by

    Ma Theresa Medrocillo
    163 views18 pages
    In liver cirrhosis, abdominal pain may be present because of recent, rapid enlargement of the liver, producing tension on the fibrous covering of the liver (Glisson's capsule) abdominal distention, caused by ascites, can cause compression of surrounding organs and overexpansion of the surrounding skin causing stimulation of pain receptors. At the end of my 3 (r) Assessment days span provides of care information my about the patient cause of pain.

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    In liver cirrhosis, abdominal pain may be present because of recent, rapid enlargement of the liver, producing tension on the fibrous covering of the liver (Glisson's capsule) abdominal distention, caused by ascites, can cause compression of surrounding organs and overexpansion of the surrounding skin causing stimulation of pain receptors. At the end of my 3 (r) Assessment days span provides of care information my about the patient cause of pain.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    163 views18 pages

    Nursing Care Plan ER

    Uploaded by

    Ma Theresa Medrocillo
    In liver cirrhosis, abdominal pain may be present because of recent, rapid enlargement of the liver, producing tension on the fibrous covering of the liver (Glisson's capsule) abdominal distention, caused by ascites, can cause compression of surrounding organs and overexpansion of the surrounding skin causing stimulation of pain receptors. At the end of my 3 (r) Assessment days span provides of care information my about the patient cause of pain.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 18

    By: Ma. Theresa Medrocillo St.

    Date

    Cues

    Need

    Nursing Diagnosis

    Objectives

    Interventions

    Evaluation

    A U G U S T 15, 2011 @ 7am

    C O Pain G Scale = 3 N severe I pain T I Facial Grimace V noted E Guarding behaviou r noted O:

    Acute Pain related to Enlarged Liver and Abdominal distention

    After my 3 days span of care my patient will be able to experience alleviation of pain as manifested by:

    1. Reassess location and character of pain when the client reports discomfort.

    August 17, 2011 Goal Partially Met

    At the end of my 3 Assessment days span provides of care information my about the patient cause of pain. was partially

    Date

    Cues

    Need

    Nursing Diagnosis
    Rationale: In liver cirrhosis, abdominal pain may be present because of recent, rapid enlargement of the liver, producing tension on the fibrous covering of the liver (Glissons capsule). Later in the disease the liver decreases in size as scar tissue contracts the liver tissue. The liver edge is palpable, is nodular. Abdominal distention, caused by ascites, can cause compression of surrounding organs and overexpansion of the surrounding skin causing stimulation of pain receptors. (Med-Surg Nursing by Bare, pp. 1102)

    Objectives

    Interventions 2. Reassess patients perception of pain intensity using a scale of 1 to 5 with 1 being the least and 5 being the most pain. Assessment provides quantitative information about patients perception of pain and guides the choice of medications. Level of pain is what the client says it is

    Evaluation

    A U G U S T 15, 2011 @ 7am

    P E R Abdomin C E al distentio P T n noted U A Dx: L CT scan and USD P A shows hepatom T T egaly E and R ascites N Ascites noted

    A. Verbalizatio n of relief from pain using the pain scale level of 0 to 1 as: 0 no pain 1 mild pain 2moderate pain 3- severe pain

    experienc ed alleviation of pain as manifeste d by:

    Date

    Cues

    Need

    Nursing Diagnosis

    Objectives

    Interventions 3. Observe nonverbal cues and pain behaviors such as how patient sleeps, sits, holds body, and facial expressions.

    Evaluation

    A U G U S T 15, 2011 @ 7am

    B. maintenanc e of her normal vital signs of: PR: 60- 100 bpm CR: 60 100 bpm RR: 16 -20 cycle Temp: 36.1 -37.2 BP: 110/70 130/90 mmHg

    a. verbali zation of relief of pain but pain still return Observations s may or may not intermi be congruent ttent with verbal cues pain indicating the
    need for further evaluation.

    Date

    Cues

    Need

    Nursing Diagnosis

    Objectives

    Interventions

    Evaluation

    A U G U S T 15, 2011 @ 7am

    c. being 4. Monitor the relaxed; not patients vital restless and signs. sighing; Vital signs are altered in acute pain. 5. Administer appropriate medication as ordered. To relieve pain

    b. maintena nce of normal vital signs of: Temp.: 36.3 C BP: 110/80 mmHg CR: 98 bpm RR: 20 cpm

    Date

    Cues

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    Nursing Diagnosis

    Objectives

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    A U G U S T 15, 2011 @ 7am

    c. being 4. Monitor the relaxed; not patients vital restless and signs. sighing; Vital signs are altered in acute pain. 5. Administer appropriate medication as ordered. To relieve pain

    c. However, the patient feels restless due to the pain and pressure felt due to abdomina l distention.

    Date

    Cues

    Need

    Nursing Diagnosis

    Objectives

    Interventions

    Evaluation

    A U G U S T 15, 2011 @ 7am

    c. being 4. Monitor the relaxed; not patients vital restless and signs. sighing; Vital signs are altered in acute pain. 5. Administer appropriate medication as ordered. To relieve pain

    Date

    Cues

    Need

    Nursing Diagnosis

    Objectives

    Interventions

    Evaluation

    A U G U S T 15, 2011 @ 7am

    6. Note the location of the surgical procedure. This can influence the amount of post operative pain experienced. Example, vertical/diagon al incisions are more painful than transverse or S-shaped ones.

    Date

    Cues

    Need

    Nursing Diagnosis

    Objectives

    Interventions

    Evaluation

    A U G U S T 15, 2011 @ 7am

    7) Assess patency of drains and catheters. Obstructed flow of urine will result in increased renal pressure and cause/intensif y pain. 8. Change dressing as indicated.

    Date

    Cues

    Need

    Nursing Diagnosis

    Objectives

    Interventions

    Evaluation

    A U G U S T 15, 2011 @ 7am

    To prevent infection which may cause added pain. 9) Encourage to have enough bed rest and rest periods. To prevent fatigue. 10) Reassess patient for pain relief. Observe for side effects.

    Date

    Cues

    Need

    Nursing Diagnosis

    Objectives

    Interventions

    Evaluation

    A U G U S T 15,

    Assessment provides information about patients response to medication. Assist patient to change position, as soon as possible. Provide comfortable environment.

    2011
    @ 7am

    Date

    Cues

    Need

    Nursing Diagnosis

    Objectives

    Interventions

    Evaluation

    A U G U S T 15, 2011 @ 7am

    Assessment provides information about patients response to medication. 11.) Assist patient to change position, as soon as possible. Provide comfortable environment.

    Date

    Cues

    Need

    Nursing Diagnosis

    Objectives

    Interventions

    Evaluation

    A U G U S T 15, 2011 @ 7am

    Position changes decreases muscle tension, comfortable environment enhances relaxation. 12.) Teach patient to ask for pain medication before pain becomes severe.

    Date

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    Need

    Nursing Diagnosis

    Objectives

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    Evaluation

    A U G U S T 15, 2011 @ 7am

    Pain medication is more effective and less is needed if given before pain is severe. 13.) Encourage and assist patient to do deep breathing exercises.

    Date

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    Need

    Nursing Diagnosis

    Objectives

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    Evaluation

    A U G U S T 15, 2011 @ 7am

    Deep breathing for relaxation is easy to learn and contributes to pain relief and/or reduction by reducing muscle tension and anxiety.

    Date

    Cues

    Need

    Nursing Diagnosis

    Objectives

    Interventions

    Evaluation

    A U G U S T 15, 2011 @ 7am

    14. Offer nonpharmacol ogical interventions if desired such as therapeutic touch, back rub, music. Nonpharmaco logical interventions may use distraction to decrease pain perception.

    Date

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    Nursing Diagnosis

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    Interventions

    Evaluation

    A U G U S T 15, 2011 @ 7am

    15. Provide psychological support/motiv ation. To ascertain the motivation for returning to an optimal level of wellness.

    Date

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    A U G U S T 15, 2011 @ 7am

    16.) Notify watcher or physician if pain is not controlled or if complications are suspected Watcher may order a different analgesic or decide to reevaluate the patient.

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