St.

Anthony’s College
San Jose, Antique
Nursing Department
NAME: E.F.J.
AGE: 42 years old
Dr.: M.A.B.
CC: RUQ pain NURSING CARE PLAN
CUES NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Acute pain Patient came to the hospital, GENERAL: INDEPENDENT: STO:
related to due to Right Upper Quadrant To deliver maximum 1. Assess Vital signs 1. Vital signs could be a After 8hours of nursing
“Sakit rugya ayun stimulation of pain. The pain is mainly due care and treatment great trick to detect interventions, the client was
(pointing to RUQ of the nerve to the gallbladder stones that to this client with gall patient response to the able to manifest a decrease of
abdomen). Daw endings. was irritating the patient’s bladder stones and condition. ↑BP may pain from7/10 to 4/10. Fully
nagasgas,kapin pa gallbladder. (as based on the to relieve from any aggravate from intense met
kung nagahulag ako”, Dx t/c Cholecystitis vs kind of discomfort pain. ↑RR, may came
as verbalized by the cholethiasis r/o from intense pain may : After 5 minutes of nursing
patient nephrolithiasis). Because of LTO: lead to hyperventilation, education, the client was able
OBJECTIVE: the gallbladder stones, the Within 2 days of ↑PR compensation of to do Deep Breathing Exercises.
Vital signs are as cell membrane of the nursing the body to pain Fully met
follows: gallbladder starts to be interventions, patient sensation, ↑T may
T: 37.0c per right disrupted. Causing the will continuously indicate infection or : After 10 minutes of nursing
axilla, BP: release of inflammatory manifest relief of disease process discussion, the client was able
120/80mmHg per response to the bloodstream. pain and no 2. Assess PQRST of 2. Characteristic of pain to enumerate as many as
right arm ---o, RR: 42 Chemical mediators such as complaints of any pain. indicates what specific possible stimuli causing pain.
cpm, PR: 109 bpm Histamine, Prostaglandin, kind of discomfort organ problem is being Fully met
per left radial pulse, Bradyikinins, and encountered. Can be
O2sat:98%; Pain Leukotrienes cause the STO: used to properly : After 5 minutes of nursing
rated as 7/10 swelling of the gallbladder. After 8hours of manage the problem interventions, the client was
characterized as Prostaglandin and nursing intervention, 3. Assess non- 3. Non-verbal cues of pain able to assume comfortable
cramping, non- Bradykinins were responsible the client will verbal cues of gives you a clue or hint position to decrease
radiating, continuous for the cramping pain on manifest a decrease pain. regarding the pain discomfort.
pain; Seen holding RUQ of the abdomen being of pain from 7/10to status of the client Fully met
RUQ of abdomen felt by the patient. In 4/10 4. Assess capillary 4. Vital signs are affected
noted, grimacing, addition, cholecystectomy is refill. by pain sensation thus, LTO:
weakness noted, indicated for the SPECIFIC: ↑PR and ↑RR which Within2 days of nursing
Capillary refill of 1- management of this disease : After 5 minutes of are responsible for interventions, patient will
2seconds problem. nursing education, proper oxygenation of continuously manifest relief of
the client will be able the cells. Must be pain and no complaints of any
to do Deep Breathing checked to see if proper kind of discomfort
Exercises distribution of nutrients *Fully met, if the patient will be
and O2 occurs. able to verbalize no complain
5. Allow patient to 5. Patient knows his body of pain.
: After 10 minutes of assume better, thus allowing
nursing discussion, comfortable him to assume a **Partially met, if patient
the client will be able position comfortable position verbalize at least a decreased
to enumerate as may help to alleviate the in pain sensation.
many as possible pain sensation thus Modify intervention or
stimuli causing pain. promoting comfort in Continue.
patient’s condition.
: After 5 minutes of 6. Promote rest and 6. Sleep could be a good ***Unmet, if still the patient
nursing sleep by example of diversion complains of intense pain.
interventions, the clustering activity to relieve pain Continue or modify
client will be able to interventions due to non-responding Interventions
assume comfortable to pain sensation by .
position to decrease closing the “gateway” of
discomfort impulses to the brain. In
addition, rest and sleep
rehydrates and
energizes the cells
7. Instruct to do 7. DBE can help relieve
Deep Breathing pain by allowing the
Exercises. release of beta
endorphins which is well
known as our natural
analgesic.