VI.

Nursing Care Plan for Cholelithiasis

ASSESSMENT DIAGNOSIS Explanation of the PLANNING INTERVENTIONS RATIONALE EVALUATION

Problem
SUBJECTIVE: Acute pain Cholelithiasis SHORT TERM INDEPENDENT:
 “Masakit ang related to I OBJECTIVE:
kanang inflammation and Further complication After 4 hours of Observe and document Assist in Short term objective
tagiliran ko” distortion of I nursing location, severity (1- differentiating of pain met if patient’s pain
as verbalized tissues as Inflammation of the interventions, 10 scale) and character and provides has been relieved or
by the patient. evidenced by Gallbladder patient’s pain will be of pain (steady, information about controlled as patient
 Pain starting patient’s I relieved or intermittent, colicky) disease demonstrates use of
suddenly and verbalization of controlled as patient (Get a baseline data of progression/resolution, relaxation skills and
Acute Cholecystitis
usually biliary colic, demonstrates use of pain scale) development of as indicated for
I
peaking in 30 facial mask of relaxation skills and complications, and individual situation.
pain, guarding Disrupting movement and as indicated for effectiveness of
minuites.
behavior, distortion of tissues individual situation. interventions.
OBJECTIVE: autonomic I Note for medication
 Facial mask responses, self- Activation of nociceptor in LONG TERM reaction and report to Any adverse reaction
of pain focusing, the dermis and tissues OBJECTIVE: the physician. to medicine can
 Muscle narrowed focus l After 5 months of constrict the Long term objective
guarding or and high BP. Receptors send impulses to series nursing bronchioles and impair met if patient’s
rigidly when CNS for interpretation interventions with breathing pattern. disease has been
right upper I collaboration with Promote bed rest, cured as manifested
abdomen Pain Perception the physician and allowing patient to Bed rest in low by patient’s pain
palpated I other health care assume position of Fowler’s position relived, homeostasis
 Autonomic Acute pain agents, patients comfort. reduces achieved and
responses diseased will be intraabdominal complications are
 Self- focusing cured as manifested pressures; however, prevented/minimized.
by patient’s pain patient will naturally
 Narrow focus
relived, homeostasis assume least painful
 Vital Signs:
achieved and position.
- T = 37.3 C
complications are
- PR = 100
prevented/minimized
- RR = 20
- BP = DEPENDENT:
140/100 Administer
medications per
physician’s order:
*refer to the Drug
study section for the
medications given
with corresponding
indicatons

COLABORATIVE:
Prepare for To condition patients
procedures; body to undergo
- abdominal procedure. Abdominal
ultrasound ultrasound creates an
image of the internal
organs and measures
the thickness of the
gallbladder wall (a
maker of inflammation
and scarring).

- - blood test To prepare the patient

for the procedure.
Blood test reveals an
increase in the white
blood count, as well as
an increase in
bilirubuin.
THERAPEUTIC:

Encourage use of Promotes rest,

relaxation techniques redirects attention,
e.g., guided imagery, may enhance coping.
visualization, deep
breathing exercises.

Make time to listen to Helpful in alleviating

complaints and anxiety and refocusing
maintain frequent attention, which can
contact with patient. relieve pain.

Control environmental Cool surroundings aid

temperature in minimizing dermal
discomfort.

EDUCATIVE:
Instruct patient to Prevents/limits
avoid food/fluids high recurrence of
in fats’ gas producers gallbladder attacks.
or gastric irritants

Recommend resting in Promotes flow of bile

semi-Fowler’s position and general relaxation
after meals. during initial digestive
process.

Suggest patient limit Promotes gas

gum chewing, sucking formation, which can
on straw/hard candy, increase gastric
or smoking. distention/discomfort.

Discuss avoidance of Reduces risk of

aspirin-containing bleeding related to
products, forceful changes in coagulation
blowing of nose, time, mucosal
straining for bowel irritation, and trauma.
movement, contact
sports. Recommend
use of soft tooth brush,
electric razor.