IX. NURSING CARE PLAN Patient Name: Medical Dx: 1.

Acute Pain Assessment Cues Subjective: Masakit yung suagt ko with pain scale of 8/10 Objective: - difficulty in moving as manifested by facial grimaces - (+) pallor - (+) muscle guarding - Restless and irritable - Observed selffocusing or narrowed focus
Limited

XXX, 20 y/o Choledocholithiasis

Planning Scientific Explanations Due to the presence of stones in the gallbladder it causes some obstruction in the cystic duct which in turn causes a sharp acute pain on the right part of the abdomen. Expected Outcome Within 1 hour of proper nursing interventions, the clients pain scale will decrease from 8/10 to 5/10 Nursing Interventions Independent: 1. Observe and document location, severity (010 scale), and character of pain (e.g., steady, intermittent, colicky). 2. Promote bedrest, allowing patient to assume position of comfort. Rationale

Evaluation Outcome Analysis a. Goal met After 30 minutes of proper nursing interventions, the clients pain scale was decreased from 8/10 to 5/10

Nursing Diagnosis Acute pain related to obstruction / ductal spasm as evidenced by verbal reports of pain.

1.Assists in differentiating cause of pain, and provides information about disease progression/resolution, development of complications, and effectiveness of interventions. 2Bedrest in lowFowlers position reduces intraabdominal pressure; however, patient will naturally assume least painful position. 3.Cool surroundings aid in minimizing dermal discomfort.

3. Control environmental temperature.

IX. NURSING CARE PLAN Patient Name: Medical Dx:

movement

XXX, 20 y/o Choledocholithiasis 4. Encourage 4. Promotes rest, use of redirects attention, relaxation may enhance coping. techniques, e.g., guided imagery, visualization, deep-breathing exercises. Provide diversional activities. 5.Helpful in 5. Make time alleviating anxiety and to listen to and refocusing attention, maintain which can relieve frequent contact pain. with patient. Dependent: 1. Administer analgesics as indicated 1. Relief of pain facilitates cooperation with other therapeutic interventions,

IX. NURSING CARE PLAN Patient Name: Medical Dx: 2. Fluid Volume deficient Assessment Cues S ubjective None Nursing Diagnosis Fluid Volume Deficient related to vomiting possibly evidenced by Scientific Explanations Because of vomiting excessive losses through normal routes occur thus causes Fluid Volume Deficient Expected Outcome After a series of NI the pt. will maintain adequate fluid volume as evidenced by moist mucous membranes and good skin turgor, XXX, 20 y/o Choledocholithiasis

Planning Nursing Interventions Independent: 1. Maintain accurate record of I&O, noting output less than Intake, increased urine specific gravity. Assess skin/mucous membranes, peripheral pulses, and capillary refill. 2. Perform frequent oral hygiene Rationale

Evaluation Outcome Analysis Partially met After a series of nursing intervention: Theres no still the presence of; a. vomiting b. dry skin c. dry mouth d. poor skin turgor e. body weakness

Objective - (+) pallor - (+) body weakness - (+) vomiting - with poor skin turgor - (+) dry skin - (+) dry mouth

1. Provides information about fluid status/circulating volume and replacement needs.

2. Decreases dryness of oral mucous membranes; reduces risk of oral bleeding. 3.Skin and mucous membranes are dry, with decreased elasticity, because of vasoconstriction and

3. Provide skin and mouth care

IX. NURSING CARE PLAN Patient Name: Medical Dx: XXX, 20 y/o Choledocholithiasis reduced intracellular water. -

4. Increase fluid intake 5. Ascertain patients beverage preferences, and set up a 24hr schedule for fluid intake. Encourage foods with high fluid content.

4. promotes hydration. 5. Relieves thirst and discomfort of dry mucous membranes and augments parenteral replacement.

Dependent: 1. Administer 1. Reduces nausea antiemetics, and prevents as ordered by the vomiting. physician.

IX. NURSING CARE PLAN Patient Name: Medical Dx: 3. Knowledge Deficit Assessment Nursing Diagnosis Deficient knowledge related to condition, prognosis, treatment, selfcare, and discharge needs possibly evidenced by frequently asking question about condition. Scientific Explanations There is this presence of knowledge deficit due to some unfamiliar information that causes some confusion to the client that needs to be discussed. Expected Outcome After an hour of nurse-patient interaction the patient will Verbalize understanding of disease process, prognosis, and potential complications. XXX, 20 y/o Choledocholithiasis

Planning Nursing Interventions Independent: 1. Provide explanations of/reasons for test procedures and preparation needed. Rationale

Evaluation Outcome Analysis Goal met:

Cues S pwede bang maulit ang sakit ko as verbalized by the patient

O - Frequently asking question about his condition, treatment and diet With worried gaze

After an hour of nurse-patient interaction the patient Verbalize understanding 2. Review 2. Provides knowledge of disease disease base from which process, process/prognosis. patient can make prognosis, and Discuss informed choices. potential hospitalization Effective complications. - there a and prospective communication and treatment as support significant indicated. at this time can changes that Encourage diminish anxiety and occur on the questions, promote healing. patients expression of knowledge concern.
regarding;

1.Information can decrease anxiety, thereby reducing sympathetic stimulation.

3. Review drug regimen, possible side effects.

3.Gallstones often recur, necessitating long-term therapy.

a. disease condition b. diet c. treatment

IX. NURSING CARE PLAN Patient Name: Medical Dx: XXX, 20 y/o Choledocholithiasis d. medication e. self-care needs

4. Instruct patient to avoid food/fluids high in fats (e.g., whole milk, ice cream, butter, fried foods, nuts, gravies, pork), gas producers (e.g., cabbage, beans, onions, carbonated beverages), or gastric irritants (e.g., spicy foods, caffeine, citrus). 5. Suggest patient limit gum chewing, sucking on straw/hard candy, or smoking.

4. Prevents/limits recurrence of gallbladder attacks.

5. Promotes gas formation, which can increase gastric distension/discomfort.