CUES

S> "Ang sakit ng opera ko.

EXPLAINATION OF THE
PROBLEM
Cholelithiasid

INTERVENTIONS

RATIONALE

EVALUATION

At the end of 72 hours

Observed for irritablitiy,

The nonverbal cues may

LTO>

nursing intervention, the

restlessness and sleep

indicate the presence or

1. Fully met: Verbalize no

Further complication

patient will be able to:

disturbances.

degree of pain.

pain at all

Inflammation of the
gallbladder

1. Report a decrease in

Observed and documented

Assist in differentiating of

Partially met: Presence of

pain intensity from 9/10 to

location, severity (1-10

pain and provides

pain with a rating of 7/0

4/10.

scale) and character of

information about disease

2. Demonstrate

pain (steady, intermittent,

progression development

Not met: Presence of pain

Disrupting movement and

distortion of tissue

nonpharmacological

colickly)

of complications and

with a rating of 5/10

methods and use

effectiveness of

Activation of nociceptor in
the dermis and tissues

relaxation skills and

interventions

Hindi siya tolerable. Basta

humihinga ako o

OBJECTIVES

gumagalaw, sumasakit
lalo. Nahihirapan din akong
makatulog."
O> Pain scale of 9/10.
Facial mask of pain.
Protecting gestures such
as covering the surgical
site. Slow and limited
movement of the
extremities. Vital signs of
BP: 140/100, RR: 26, PR:

Acute cholecystitis

Receptors send impulses

to CNS for interpretation

89, T: 36.7

diversional activites as
indicated.
After 8 hours of nursing

Pain receptors
Acue pain

2. Fully met: Shows

distracting activities such

Noted for medication

Any adverse reaction to

as interacting well with

reaction and report to the

medicine can constrict

relatives and able to do

physician.

brochioles and impairs

deep breathing exercises

breathing pattern.

simultaneously.

intervention, the patient will

be able to:
1. Return to its normal

Demonstrated deep

Deep breathing exercises

STO>

sleeping time which is from

relaxation techniques.

can help in relieving the

1. Fully met: Able to rest

pain.

and get an optimum sleep

3 hours to 6 hours.
2. Diminish nonverbal cues

of at least 6 hours

such as grimacing and

restlessness.

Partially met: Still with a

little difficulty of sleeping

Promoted bed rest allowing

Bed rest in low fowlers

but able to sleep until 5

patient to assume position

position reduces

hours

of comfort.

intrabdominal pressure.
Not met: Gets a sleep of

Provided bedside care like

Promotion of environment

less than 3 hours per day

stretching linens.

increases comfort.

of hospitalization

Instructed on positioning

For promotion of comfort.

2. Fully met: Will not

every 2 hours.

manifest any nonverbal

indications such as
grimacing
Partially met: More time
that the patient is calm and
sometimes grimacing
Not met: Observes
grimacing many times
during the shift.