Jean Paola M.

Nolasco

BSN004- GROUP 15

Nursing Care Plan

 Cues Nursing Analysis and Goals and Interventions Rationale Evaluation
Diagnosis Interpretation Objectives
Subjective Cues: Goal:
Alteration in Cholecystitis After 4 hours
- “lagi akong comfort with of nursing
nahihilo, related to cholelithiasis is interventions,
sumasakit ang ulo inflammator an acute or the client will
ko tapos y process chronic report that pain
nagsusuka” inflammation of is controlled
the gallbladder and lessened.
- “sobrang sakit associated with The pain will
ng tyan ko, sa obstruction by decrease from
banding kanan gallstone(s) of 9 to 4 based on
hanggang likod the cystic or the pain scale.
ko sumasakit” common bile
ducts. Stones are Objectives:
- “ matagal bago made up of After nursing
mawala yung cholesterol, interventions, After nursing
sakit, minsan calcium the client will interventions,
umaabot ng billirubinate or a be able to: the client was
limang oras, mixture caused able to:
mawawala tapos by changes in the Supplemental
babalik din, bile composition.
madalas sa gabi Cholecystitis, an 1. Have a 1. Observe and document 1. Assists in differentiating 1.have a
nagsisimula” acute baseline data location, severity (0-10 cause of pain. and provides baseline data
complication of about her scale), and character of information about disease about her
- pain scale : 9 cholelithiasis, is current status pain. (e.g., steady, progression/resolution, current status
(pain scale: 1-10, an acute intermittent or colicky) development of complications,
10 being the most infection of the and effectiveness of
painful) bladder. acute interventions.
pain comes from
Objective Cues: the chemical 2. Report 2. Note response to 2. Severe pain not relieved by 2. voice out if
irritation of the response to medication, and report to routine measures may indicate the pain is
- abdominal peritoneum and medication. physician if pain is not developing complications/ need relieved by
distension is a part of the being relieved. for further interventions. medication or
inflammatory not.
- tachycardia, process.
diaphoresis 3. have 3.1 Promote bed rest, 3. Bed rest, in semi-fowler’s 3. voice out
Source: increased allowing client to assume position reduces intra-abdominal feelings of
- hypoactive Handbook for comfort. position of comfort. pressure; however, client will comfort and
bowel sounds the Textbook of naturally assume least painful decreased
Medical-Surgical position. painful
- (+) guarding Nursing, 11th sensations.
bahavior edition by 3.2 Use soft/cotton linens, 3.2 Reduce irritation/dryness of