Assessment

S> Masakit dito (pointing to RUQ of abdomen). Para syang nagagasgas, lalo na pag gumagalaw ako. Di naman maiwasang gumalaw kase madami din ginagawa. O> Vital signs are as follows: T: 36.5c per right axilla, BP: 120/80 mmHg per right arm ---o, RR: 18 cpm, PR: 82 bpm per left radial pulse, +2; Pain rated as 7/10 characterized as cramping, non-radiating, continuous pain; Seen holding RUQ of abdomen noted, grimacing, weakness noted, Capillary refill of 1-2 seconds, ultrasound reveals stone formation and deposition in the gall bladder. A> Acute pain related to stimulation of the nerve endings.

Explanation of the Problem

Patient came to Emergency Room from OPD, due to Right Upper Quadrant pain. The pain is mainly due to the gall bladder stones that was irritating the patients gallbladder. (as revealed by the Ultrasound). Because of the gallbladder stones, the cell membrane of the gallbladder starts to be disrupted. Causing the release of inflammatory response to the blood stream. Chemical mediators such as Histamine, Prostaglandin, Bradyikinins, and Leukotrienes cause the swelling of the gallbladder. Prostaglandin and Bradykinins were responsible for the cramping pain on RUQ of the abdomen being felt by the patient. In addition, cholecystectomy is indicated for the management of this disease problem.

Goals and Objectives

Goal: To deliver maximum care and treatment to this client with gall bladder stones and to relieve from any kind of discomfort. LTO: Within 3 days of nursing interventions, patient will continuously manifest relief of pain and no complaints of any kind of discomfort. STO: After 30 minutes of nursing interventions, the client will manifest a decrease of pain from 7/10 to 4/10. : After 5 minutes of nursing education, the client will be able to do Deep Breathing Exercises. : After 10 minutes of nursing discussion, the client will be able to enumerate as many as possible stimuli causing pain. : After 5 minutes of nursing interventions, the client will be able to assume comfortable position to decrease discomfort.

Interventions

Rationale
to detect patient response to the condition. BP may aggravate from intense pain. RR, may came from intense pain may lead to hyperventilation, PR compensation of the body to pain sensation, T may indicate infection or disease process. 2. Characteristic of pain indicates what specific organ problem is being encountered. Can be used to properly manage the problem. 3. Non-verbal cues of pain gives you a clue or hint regarding the pain status of the client. 4. Vital signs are affected by pain sensation thus, PR and RR which are responsible for proper oxygenation of the cells. Must be check to see if proper distribution of nutrients and o2 occurs. 5. Patient knows better her body, thus, allowing her to assume her comfortable position may help to alleviate the pain sensation thus promoting comfort in patients condition. 6. Sleep could be a good example of diversion activity to relieve pain due to non-responding to pain sensation by closing the gateway of impulses to the brain. In addition, rest and sleep, rehydrates and energizes the cells. 7. DBE can help relieve pain by allowing the release of bte endorphins which is well known as our natural analgesic. 8. Diversional activity closes the gateway of pain nerve impulses, thus it wont reach the pain center of the brain producing NO pain sensation or atleast, drcreased.

Evaluation
STO: After 30 minutes of nursing interventions, the client able to manifest a decrease of pain from 7/10 to 4/10. Fully met : After 5 minutes of nursing education, the client was able to do Deep Breathing Exercises. Fully met : After 10 minutes of nursing discussion, the client was able to enumerate as many as possible stimuli causing pain. Fully met : After 5 minutes of nursing interventions, the client was able to assume comfortable position to decrease discomfort. Fully met LTO: Within 3 days of nursing interventions, patient will continuously manifest relief of pain and no complaints of any kind of discomfort. * Fully met, if the patient will be able to verbalize no complain of pain. ** Partially met, if patient verbalize at least a decreased in pain sensation. Modify intervention or Continue. ***Unmet, if still the patient complains of intense pain. Continue or modify Interventions.

1. Assess Vital signs. 1. 1. Vital signs could be a great trick

2. Assess PQRST of 2. pain. 3. Assess non-verbal3. cues of pain. 4. Assess capillary refill. 4.

5. Allow patient to 5. assume comfortable position. 6. Promote rest and 6. sleep by clustering interventions.

7. Instruct to do Deep Breathing 7. Exercises. 8. Advice to do 8. diversional activities such as reading books.

Page 3 of 3 NURSING CARE PLAN PROPER