Nursing Care Plan

Cues Nursing Background Goal and Nursing Interventions Evaluation

Diagnosis knowledge Objectives and Rationale
Subjective: Acute pain Ulcerative Colitis is Goal: Aftter the Goal met
- “my stomach hurts so much related to caused by chronic, nursing
I can barely take the pain” prolonged long-term interventions, the The client
Objective: diarrhea and inflammation that client will report report
- pain of 9/10 skin/tissue leads to open sores relieve of pain relieved of
- Pain in left lower abdominal irritation as known as ulcers in pain with a
quadrant that is sharp, evidenced by the innermost pain scale of
constant, and aggravated by abdominal pain lining of your Objectives: 0 out of 10
movement colon, or large
- BP to 85/47 intestine, and After 8 hours of
- HR 130 rectum.  Abdominal nursing
- RR 29 cramping and mild interventions, the
- tympanic temperature of to severe pain in client will be able
38.9°C both the abdomen to:
- O2 sat. 96% and rectum are
- Uncomfortable; quietly common. The pain 1. Verbalize 1. Administer 1
crying and lying on her left may be long- of reduced mg of
side with her knees flexed lasting, or it may pain with morphine
and arms holding her fade when the pain scale sulfate IV
abdomen inflammation of 0 out of push. Reassess
recedes. (Whelan, 10 pain after 15
2019) mins. Note: if
pain still
persist
administer
additional 2 mg
of morphine
sulfate and
continue
reassessing
pain.
Rationale: to
treat and
 manage severe
pain

2. Administer 400
mg of
hydrocortisone
IV. Rationale:
to decrease
inflammation

3. Monitor pain
and manage
with scheduled
IV infusion of
acetaminophen
(Ofirmev) 1000
mg every 6
hours and 1 mg
morphine
sulfate IV push
for
breakthrough
pain.
Rationale:
to manage
mild-to-
moderate pain
or moderate-to-
severe pain
with an
adjunctive
opioid. It can
also be used to
reduce fever.

Non- pharmacologic:
4. Encourage
patient to
assume
position of
comfort (knees
flexed).
Rationale:
Reduces
abdominal
tension and
promotes sense
of control.

5. Provide
comfort
measures (back
rub, reposition)
and diversional
activities.
Rationale:
Promotes
relaxation,
refocuses
attention, and
may enhance
coping
abilities.