Cues/ Evidences

SUBJECTIVE
Verbalized sharp,
burning pain with
an intensity rating
of 5 on the scale of
1-10 at the
epigastric area.
OBJECTIVE
Slight facial
grimacing noted
Minimal
perspiration
Guarding of
abdomen upon
movement
Frequent touching
of epigastric region
Ultrasound Report:
The gallbladder is
normal in size and
configuration. A 0.8
cm intense echo is
noted within the
lumen with
characteristic
shadowing
posteriorly.

Nursing
Diagnosis

Objectives

Altered Comfort:
Acute Pain related
to the presence of
0.8 cm stone in
the gallbladder.

Within our 8 hours

nursing care, the patient
will have a decrease
perception of pain as
evidenced by:

vital signs will be

maintained at normal
limits
verbalization of
minimal relief from
discomfort
pain rating is 3 on
the scale 1-10
absence of
expressive behaviors
such as restlessness
and facial grimacing
appears relax
identify at least 5
strategies to maintain
an acceptable
comfort level

Intervention
1. Perform a complete
comprehensive
assessment of pain
to include location,
characteristics,
onset, duration, and
quality.
2. Encourage the
patient to verbalize
feelings regarding
pain experience.
3. Reduce or eliminate
factors that
precipitate or
increase pain
experience.
4. Manipulate the
environment as
necessary such as
maintaining a clean,
wrinkle-free bed.
5. Offer back rub to
the patient.
6. Encourage the use
of stress
management
techniques, such as
deep breathing
exercises.

Rationale
According to Ida Jean Orlandos
Nursing Process Discipline, nurses
action should be deliberative, rather
than automatic. It should explore the
meaning and relevance of an action.

Pain is a subjective experience and

must be described by the client in
order to plan effective treatment.
Environmental and personal factors
can influence pain and these could be
reduced or eliminated to enhance
overall pain management program.
Florence Nightingale focused on
changing and manipulating the
environment to put patient in the best
possible conditions for nature to act.
Back rub is a procedure that relaxes
the patient and relieves muscle
tension.
Stress management techniques
increase the release of endorphins and
increase the therapeutic effects of
medication.

Evaluation
After our 8 hours
nursing care, the patient
was able to have a
decrease perception of
pain as evidenced by:
GOAL MET
Maintained vital
signs within normal
limits
T= 36 C
P= 72 bpm
R= 18 cpm
BP= 120 mmHg
GOAL MET
Verbalized relief
from discomfort
GOAL MET
Rated pain as 2 on
the scale of 1-10
GOAL MET
Showed absence of
expressive behaviors
such as restlessness
and facial grimacing
GOAL MET
Appeared relax
GOAL PARTIALLY

7. Provide rest periods

and position patient
in semi-Fowlers
position.
COLLABORATIVE
1. Administer
Omeprazole 40 mg
IVTT as ordered.

Patients pain experience may be

come exaggerated as a result of
fatigue and semi- Fowlers position
reduces intraabdomnial pressure.

Suppresses gastric acid secretion by

specific inhibition of the
hydrogen/potassium ATPase enzyme
system at the secretory surface of the
gastric parietal cells.

MET
Identified only 3
strategies to maintain
an acceptable
comfort level