Case presentation

by delmas and manglapus

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General data: Chief Complaint:

EPIGASTRIC PAIN
Name: A.C.
Age: 54 y/0
Gender: Female
Religion: R.C.
Nationality: Filipino
Civil Status: Married
Date of admission: March 6, 2019
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HISTORY OF PRESENT ILLNESS

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PAST MEDICAL HISTORY

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FAMILY HISTORY
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SOCIAL AND ENVIRONMENTAL

HISTORY
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Pathogenesis Acute
cholecystisis
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prioritization
• Acute pain related to tissue trauma
secondary to s/p open cholecystectomy

• Excess fluid volume related to increase

fluid intake
Nursing care plan: problem #1
• Acute pain related to tissue trauma secondary to s/p open
cholecystectomy
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Subjective data:

“masakit parin yung sugat ko “ pain

rated 8/10, characterized as
cramping to burning sensation non
radiating, aggravated by movement, Place your screenshot here
relieved by medication.

Objective data:
Slowed movement
Guarding
Grimacing
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Goals and objetives

Goal: Relief of Pain LTO: after 1 week of nursing
intervention, the patient will
STO: after 8 hours of nursing verbalize tolerable pain.
intervention, the patient will be able
to report a decrease in pain from
8/10 to less than 5/10.
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Interventions
diagnostic therapeutic Educative

Dependent
1. Assess pain 1. Administer pain 1. Encourage deep
characteristics medications as ordered breathing exercises
2. Assess for signs and Independent: 2. Encourage to ambulate
symptoms relating to 1. Provide cutaneous 3. Encourage to eat foods
pain stimulation rich in protein and vit
3. Monitor VS 2. Get rid of additional C
stressor 4. Encourage to do
divertional activities
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EVALUATION
STO:
Fully met as evidenced by
Patient was able to report a decrease in pain from
8/10 to 4/10

LTO:
Fully met as evidenced by reports of tolerable pain
by the patient
Nursing care plan: problem #2
• Excess fluid volume related to increase fluid intake
cues
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Subjective
“Nagmamanas na paa at kamay ko”
Objective
Bilateral pedal and palmar edema
Oliguria (15-25 ml per hour)
Concentrated urine output
Intake exceeds output
BP: 130/70 mmHg
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Goals and objectives

STO: After 8 Hours of nursing intervention, the patient
is normovolemic as evidenced by urine output
greater than or equal to 30 mL/hr.
After 8 Hours of nursing intervention, the
patient’s BP is within 90/60 to 120/80 mmHg

LTO: After 72 hours of nursing interventions, the

patient is able to balance intake and output.
After 72 hours of nursing interventions, the
patient have no signs of edema
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Interventions
Diagnostics Therapeutic Educative
1. Review patient’s history to Independent 1. Instruct patient, caregiver,
determine the probable cause Elevate edematous and family members
of the fluid imbalance. extremities, and regarding fluid restrictions,
2. Monitor input and output handle with care as appropriate.
closely. 2. Educate patient and family
3. Record intake if patient is on members regarding fluid
fluid restriction. Dependent
volume excess and its causes.
4. Monitor and note BP 1. Take diuretics as
prescribed.
3. Educate patient and family
5. Assess urine output in members the importance of
response to diuretic therapy. 2. Limit sodium
proper nutrition, hydration,
6. 6Note for presence of edema intake as
and diet modification.
by palpating over the tibia, prescribed
ankles, feet, and sacrum.
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EVALUATION
STO:
Fully met as evidenced by having a urine output
equal to 30 mL/hr and patient’s BP is within
90/60 to 120/80 mmHg

LTO:
Fully met as evidenced by
Being able to consume 300 ml f water and output
of 250 for our 8hour shift and she has no signs of
edema.
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Any questions?