NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE: Acute pain may be related After nursing interventions, Independent: After nursing interventions,
to obstruction of pancreatic the patient will: the patient will demonstrate
OBJECTIVE: as evidenced by reports of  Maintain bedrest  Decreases the use of relaxation skills
pain and observed evidence  Follow prescribed during an acute metabolic rate and and will follow the
Dizziness noted; nasal pharmacological GI stimulation and
of pain. attack. Provide a prescribed therapeutic
flaring noted; use of regimen. secretions, thereby
quiet, restful regimen.
accessory muscle noted; reducing pancreatic
environment.
irritability noted; excessive  Verbalize activity.
sweating noted; yellowish nonpharmacological  Promote a position
discoloration in the eyes methods that of comfort on one  Reduces abdominal
noted. provide relief. side with knees pressure and tension
flexed, sitting up, , providing some
02Sat: 94%  Demonstrate use of measure of comfort
and leaning
relaxation skills and and pain relief. 
PR: 103bpm forward.
verbalize sense of Note: Supine positi
RR: 24cpm control of response on often increases
to acute situation pain.
T: 36.3C and positive outlook  Provide alternative
for the future. comfort measures  Promotes relaxation
BP: 136/85mmHg (back rub), and enables the
encourage patient to refocus
relaxation attention; may
techniques (guided enhance coping.
imagery,
visualization), and
quiet diversional
activities (TV,
radio).

 Maintain  Pancreatic enzymes

meticulous skin can digest the skin
care, especially in and tissues of the
 presence of draining abdominal wall,
abdominal wall creating a chemical
fistulas. burn.

 Withhold food and  Limits and reduces

fluid as indicated. the release of
pancreatic enzymes
and resultant pain.
 Prepare  Surgical exploration
for surgical interven may be required in
tion if indicated. presence of
intractable pain and
complications
involving the biliary
tract, such as a
pancreatic abscess
 Accept the client’s or pseudocyst.
description of pain.
 Pain is a subjective
experience and
cannot be felt by
others.
 Provide comfort  To promote
measure. nonpharmacological
pain management.
 Encourage adequate
rest period.  To prevent fatigue.

Dependent:

 Administer  Severe and prolong
analgesics in a ed pain can
timely manner aggravate shock and
(smaller, more is more difficult to
frequent doses), as relieve, requiring
ordered. larger doses of
medication, which
can mask
underlying
problems and
complications and
may contribute to
respiratory depressi
on.
 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE: Ineffective Breathing After nursing interventions,
Pattern related to pleural the patient will:
OBJECTIVE: effusion.
 Maintains an
Dizziness noted; nasal
effective breathing
flaring noted; use of pattern, as
accessory muscle noted;
evidenced by
irritability noted; excessive relaxed breathing at
sweating noted; yellowish
normal rate and
discoloration in the eyes depth and absence
noted. of dyspnea.
02Sat: 94%
 Patient’s respiratory
PR: 103bpm rate remains within
established limits.
RR: 24cpm
 Patient indicates,
T: 36.3C either verbally or
through behavior,
BP: 136/85mmHg
feeling comfortable
when breathing.
 Assess and record  It is important to act After nursing interventions,
respiratory rate and when there is an the patient will:
alteration in
depth at least every
breathing patterns  Maintains an
4 hours.
to detect early signs effective breathing
pattern, as
of compromise on
the respiratory evidenced by
relaxed breathing at
system.
 Assess ABG levels normal rate and
 This monitors depth and absence
according to facility
oxygenation and of dyspnea.
policy.
ventilation status.
 Observe breathing  Patient’s respiratory
patterns.  Unusual breathing rate remains within
patterns may imply established limits.
an underlying
disease process or  Patient indicates,
either verbally or
dysfunction.
through behavior,
 Auscultate breath
 To detect decreased feeling comfortable
sounds at least
or adventitious when breathing.
every 4 hours.
breath sounds.
 Assess for the use
 Work of breathing
of accessory
increases greatly as
muscle.
lung compliance
decreases.

 Observe for  These signs signify

retractions or an increase in
flaring of nostrils. respiratory effort.

 Pain can result from

 Assess for thoracic shallow breathing.
or upper abdominal
pain.
 For management of
 Administer oxygen
underlying
at the lowest
pulmonary
concentration
condition,
indicated and
respiratory distress,
prescribed
or cyanosis.
respiratory
medications.

 Direct client in  To assist client in

breathing efforts as “taking control” of
needed. Encourage the situation,
slower and deeper especially, when
respirations and use condition to
of the pursed-lip associated with
technique. anxiety and air
hunger.

 To maximize
 Emphasize the
respiratory effort.
importance of good
posture and
effective use of
accessory muscle.