nursing care plan er

8/3/2019 Nursing Care Plan ER

http://slidepdf.com/reader/full/nursing-care-plan-er 1/18

By: Ma. Theresa Medrocillo St.N



Date Cues Need NursingDiagnosis

Objectives Interventions Evaluation

AU

GUST

15,

2011

@

7am

O:

PainScale = 3severepain

Facial

Grimacenoted

Guardingbehaviour noted

C

O

G

N

I

T

I

VE

-

Acute Painrelated to

EnlargedLiver andAbdominaldistention

After my 3days span

of care mypatient willbe able toexperiencealleviationof pain as

manifestedby:

1. Reassesslocation

andcharacterof painwhen theclientreports

discomfort.

® Assessmentprovidesinformationabout thecause of pain.

August17, 2011

“ Goal

PartiallyMet”

At the endof my 3days spanof caremypatientwaspartially





AU

GUST

15,

2011

@

7am

Ascitesnoted

Abdominaldistention noted

Dx:

CT scanand USDshowshepatomegalyandascites

PE

RCEPTU

AL

PAT

TERN

Rationale: In livercirrhosis, abdominalpain may be present

because of recent,rapid enlargement ofthe liver, producingtension on thefibrous covering ofthe liver (Glisson’s capsule). Later inthe disease the liverdecreases in size as

scar tissue contractsthe liver tissue. Theliver edge ispalpable, is nodular.Abdominaldistention, causedby ascites, cancause compressionof surrounding

organs and over-expansion of thesurrounding skincausing stimulationof pain receptors.(Med-Surg Nursingby Bare, pp. 1102)

A.Verbalizatio

n of relieffrom painusing thepain scalelevel of 0 to1 as:

0 – no pain1 – mild pain2-

moderatepain3- severepain

2. Reassesspatient’s

perception ofpain intensityusing a scale of1 to 5 with 1being the leastand 5 being themost pain.

® Assessmentprovidesquantitativeinformationabout patient’s

perception ofpain and guidesthe choice ofmedications.Level of pain iswhat the clientsays it is

experienced

alleviationof pain asmanifested by:





AU

GUST

15,

2011

@

7am

B.maintenanc

e of hernormal vitalsigns of:

PR: 60- 100bpm

CR: 60 – 100 bpm

RR: 16 -20cycle

Temp: 36.1-37.2BP:110/70 – 130/90mmHg

3. Observenonverbal cues

and painbehaviors suchas how patientsleeps, sits,holds body, andfacialexpressions.

® Observationsmay or may notbe congruentwith verbal cuesindicating the

need for furtherevaluation.

a. verbalization

ofreliefof painbutpainstill

returns – intermittentpain





AU

GUST

15,

2011

@

7am

c. beingrelaxed; not

restless andsighing;

4. Monitor thepatient’s vital

signs.

® Vital signsare altered inacute pain.

5. Administerappropriatemedication asordered.

® To relievepain

b.maintena

nce ofnormalvital signsof:Temp.:36.3 ºC

BP:110/80mmHgCR: 98bpmRR: 20cpm





AU

GUST

15,

2011

@

7am




signs.



® To relievepain

c.However,

thepatientfeelsrestlessdue to thepain and

pressurefelt due toabdominaldistention.





AU

GUST

15,

2011

@

7am




signs.



® To relieve

pain





AU

GUST

15,

2011

@

7am

6. Note thelocation of the

surgicalprocedure.

® This caninfluence theamount of

post operativepainexperienced.Example,vertical/diagonal incisions

are morepainful thantransverse orS-shapedones.





AU

GUST

15,

2011

@

7am

7) Assesspatency of

drains andcatheters.

® Obstructedflow of urinewill result in

increasedrenal pressureandcause/intensify pain.

8. Changedressing asindicated.





AU

GUST

15,

2011

@

7am

® To preventinfection

which maycause addedpain.

9) Encourageto have

enough bedrest and restperiods.

® To preventfatigue.

10) Reassesspatient forpain relief.Observe forside effects.





AUGUST

15,

2011

@

7am

® Assessmentprovidesinformationaboutpatient’s

response tomedication.

Assist patientto changeposition, assoon aspossible.

Providecomfortableenvironment.





AU

GUST

15,

2011

@

7am

® Assessmentprovides

informationaboutpatient’s

response tomedication.

11.) Assistpatient tochangeposition, assoon aspossible.

Providecomfortableenvironment.





AU

GUST

15,

2011

@

7am

® Positionchanges

decreasesmuscletension,comfortableenvironmentenhances

relaxation.

12.) Teachpatient to askfor painmedication

before painbecomessevere.





AU

GUST

15,

2011

@

7am

® Painmedication is

more effectiveand less isneeded ifgiven beforepain is severe.

13.)Encourageand assistpatient to dodeepbreathing

exercises.





AU

GUST

15,

2011

@

7am

Deepbreathing for

relaxation iseasy to learnandcontributes topain reliefand/or

reduction byreducingmuscletension andanxiety.





AU

GUST

15,

2011

@

7am

14. Offernonpharmacol

ogicalinterventions ifdesired suchas therapeutictouch, backrub, music.

® Nonpharmacologicalinterventionsmay use

distraction todecrease painperception.





AU

GUST

15,

2011

@

7am

15. Provide

psychologicalsupport/motivation.

® To ascertainthe motivation

for returningto an optimallevel ofwellness.





AU

GUST

15,

2011

@

7am

16.) Notify

watcher orphysician ifpain is notcontrolled or ifcomplicationsare suspected

® Watchermay order adifferentanalgesic ordecide to re-

evaluate thepatient.

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