Co lle ge o f Nu rsin g Silliman University Dumaguete City NURSING CARE PLAN

Cues and Evidences

Subjective: a.Sought admission due to on and off severe abdominal pain for 2 days b. Rated pain as 10 on a scale of 0-10, where 0 as no pain and 10 as the most painful Objective: a. Facial grimacing, abdominal guarding, and profuse sweating not4ed every time she complains of pain b. Laboratory exam: WBC- 18,000/cumm

Nursing Diagnosis
Altered comfort: Pain r/t Distention of intestinal tissues by inflammation

Objectives
At the end of my care, the client will manifest diminished pain as evidenced by:

Nursing Interventions
Independent: Assess pain, noting location, characteristics, severity (010 scale). Investigate and report changes in pain as appropriate. Monitor vital signs

Rationale

Evaluation

a. Rate pain within 4-6 in a scale of 10 b. vital signs within normal range: RR: 16-20cpm PR: 60-100bpm T: 36.5C-37.5C BP: 110-140/6090mmHG c. Verbalize reduced feeling of pain

Useful in monitoring effectiveness of medication, progression of healing. Changes in characteristics of pain may indicate developing abscess/peritonitis, requiring prompt medical evaluation and intervention.

When a patient is experiencing pain, there is an increased in pulse rate and respiratory rate which serves as an objective data of the existence of pain.

Monitor laboratory results

d. Minimal or no facial
grimacing e. Minimal or no abdominal guarding

Keep at rest in semiFowlers position.

Gravity localizes inflammatory exudate into lower

abdomen or pelvis, relieving abdominal tension, which is accentuated by supine position.

Provide diversional
activities. (e.g., imagery, distraction techniques)

f. Minimize profuse
sweating g. Appear relaxed, able to sleep/rest appropriately.

Refocuses attention, promotes relaxation, and may enhance coping abilities.

h. Demonstrate use of relaxation skills and diversional activities as indicated for individual situation i. Laboratory exam within normal: WBC: 4.5 -11T/cumm