GOAL / NURSING

DIAGNOSIS ANALYSIS RATIONALE EVALUATION

OBJECTIVES INTERVENTION
Cholelithiasis also known is
Acute pain Gallbladder. Gallstones are By the end of
related to concretions that form in the biliary March 31, 2010,
severe tract, usually in the gallbladder. the client will
epigastric pain Gallstones are formed within the report pain is
as evidenced gallbladder, an organ that stores relieved and
by bile excreted from the liver. Further controlled
complications of gallbladder disease
I. The woman include gallstone pancreatitis,
said that she is gallstone ileus, biliary cirrhosis, and After 30 minute of
experiencing gallbladder cancer. Gallstones may nursing a. Note clients’ age
vague be as small as a grain of sand, or intervention the and current To assess client’s Was the client’s
epigastric they may become as large as an client’s condition affecting ability to report etiologic factors
discomfort inch in diameter, depending on how 1.Etiologic factors ability to report pain pain assessed?
after meals long they have been forming. A will be assessed parameters.
and after stone blocking the opening from the Yes
eating gallbladder or cystic duct usually No
hamburger produces symptoms of biliary colic, To help Why
and French which is right upper abdominal pain b. Assess for
determine
fries. that feels like cramping. If the stone referred pain, as
does not pass into the duodenum, appropriate. possibility of
0. Weak but continues to block the cystic underlying
looking, duct, acute cholecystitis results. condition or
guarding Gallbladder calculi are relatively organ dysfunction Was the client’s
behaviour, uncommon in children. a. Ob tain client’s requiring pain response
points to Source: 2.Pain response asessment of pain treatment evaluated?
location of pain http://www.articlesbase.com/diseas will be evaluated to include location,
and crying with es-and-conditions- characteristic, To rule out Yes
difficulty onset, duration, No
articles/cholelithiasis-definition- worsening of
breathing frequency, quality, Why
causes-symptoms-and-treatment- intensity and underlying
177458.html precipitating condition
M BP-130/80 factors.
Temp-37.8
RR-21
PR-85 b. Observe
nonverbal cues of
pain behaviors Pain is subjective
 experience and
cannot be felt by
others.
c. Monitor skin color
and vital signs It is usually
altered in acute
Was the client’s able
pain to explore methods in
3. To assist client alleviating pain?
to explore methods
for alleviation of a. Determine factors
pain. in client’s lifestyle Yes
No
To determine the Why
b. Note when pain underlying cause
occurs
To medicate
prophylactically,
c. Provide comfort as appropriate
measures like
touch, positioning, To promote
heat/cold packs nonpharmacologi
quiet environment cal pain
and calm activities
management

d. Encourage use of
relation techniques
To distract
such as breathing,
cd, imagings attention and
reduce tension
e. Review
porcedures/expectat To reduce
ions and tell client concern of the
when treatment unknown and
may cause pain associated
muscle tension
f.Administer
analgesics as To maintain
indecated
 acceptable level
g. Evaluate the of pain
clients’ response to
analgesia Helps in self-
management of
pain