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Case Study Cholelithiasis

The patient reported severe abdominal pain radiating to the back rated at 9/10 on the pain scale. An assessment found signs of acute pain including dilated pupils, restlessness, irritability, increased vital signs. A diagnosis of cholelithiasis or gallstones was made. The nursing care plan included administering analgesics, monitoring vital signs, educating the patient, and preparing for possible surgery to remove the gallbladder causing the pain. The short term goal was to lessen the patient's pain to a 5/10 within 30 minutes and long term goal was to relieve the pain and allow normal activities after hospitalization.

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Jes Saryl
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1K views2 pages

Case Study Cholelithiasis

The patient reported severe abdominal pain radiating to the back rated at 9/10 on the pain scale. An assessment found signs of acute pain including dilated pupils, restlessness, irritability, increased vital signs. A diagnosis of cholelithiasis or gallstones was made. The nursing care plan included administering analgesics, monitoring vital signs, educating the patient, and preparing for possible surgery to remove the gallbladder causing the pain. The short term goal was to lessen the patient's pain to a 5/10 within 30 minutes and long term goal was to relieve the pain and allow normal activities after hospitalization.

Uploaded by

Jes Saryl
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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II.

NURSING CARE PLAN ASSESSMENT DIAGNOSIS ANALYSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE: Sobrang sakit ng sikmura ko na umaabot sa likod as verbalized by the patient.

Acute pain related to the presence of calculi or stones in the gallbladder as manifested by the verbal Pain scale = reports of the 9/10 patient and by the non-verbal OBJECTIVES: cues observed - dilated pupils and measured - facial by the nurse grimace such as - restlessness changes in - irritability vital signs, - VS: irritability, BP: 140/90 restlessness, mmHg facial RR: 26 cpm grimacing and PR: 103 bpm pupil dilation. T: 37.3 C

Cholelithiasis is the presence of stones in the gallbladder or bile duct causing obstruction in the outflow of bile resulting in an inflammatory process involving the biliary system causing pain in the epigastrium radiating to the back.

STG: Within 30 minutes of nursing intervention, the patient will verbalize that the pain lessens from pain scale of 9/10 to 5/10 and will no longer become irritable, and restless. LTG: Within hospitalization the patient will verbalize that the pain is relieve and will be able to return to his normal daily activities without any destruction cause by pain.

- Monitor vital signs. - Administer analgesics as ordered. - Assess the client s description of pain appropriately. - Perform a comprehensiv e physical examination.

- to obtain baseline data - to alleviate pain - to rule out what really causes pain

- to rule out the possibility of gallbladder perforation that needs immediate interventions - for the Position the patient to be client in a able to rest semi-fowler s and to position. prevent fatigue Provide quiet - to reduce tension on environment. the inflamed gallbladder and to provide good lung expansion thus, reducing pain - to alleviate pain Teach client to use relaxation exercises such as breathing. - to prepare Prepare the the patient in patient to any removing the surgery as entity that necessary. causes pain

STG: After 30 minutes of nursing intervention the patient verbalized that the pain lessened from pain scale of 9/10 to 5/10 and didn t manifest any signs and symptoms related to occurrence of pain. LTG: After hospitalization the patient verbalized relieved of pain and was able to return to his normal daily activities without any interference caused by pain.

- to alleviate pain on the - Post surgically, incision site provide pain after the management surgical measures on procedure the incision and to site and prevent any monitor occurrence of patient for any complication signs and symptoms of - to ensure any continuing complication. home base - Discuss with care the client the discharge planning for continuous interventions.

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