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Nursing Care Plan

The nursing care plan is for a patient experiencing abdominal pain due to inflammation of the diverticula. The plan involves monitoring vital signs, elevating the head of the bed, providing bed rest during severe pain, administering pain medication, and performing non-pharmacological pain relief techniques. The evaluation will assess if the patient expresses relief of painful symptoms and a decrease in pain severity within 1 hour of interventions.

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109 views23 pages

Nursing Care Plan

The nursing care plan is for a patient experiencing abdominal pain due to inflammation of the diverticula. The plan involves monitoring vital signs, elevating the head of the bed, providing bed rest during severe pain, administering pain medication, and performing non-pharmacological pain relief techniques. The evaluation will assess if the patient expresses relief of painful symptoms and a decrease in pain severity within 1 hour of interventions.

Uploaded by

Adha
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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NURSING CARE PLAN

NURSE Masakit yung


STATION tiyan ko!

ASSESSMENT
OBJECTIVE:
• RLQ: Diminished
NURSE bowel sounds
• Constipated
STATION
SUBJECTIVE: • Bloated
“Masakit yung tiyan • Restlessness
ko!” as verbalized by • Pain in left lower
the patient. abdomen
• Pain scale: 5/10
• Vital Signs:
-BP: 132/80 mmHg
-PR:92 bpm
-Temp.: 37.5℃

ASSESSMENT
DIAGNOSIS:
Acute Pain related to Inflammation of
Diverticula as evidenced by
Verbalization of in Left Lower
Quadrant, Pain Scale of 5/10, and
Restlessness
PLANNING:
Within 1hr. of nursing interventions,
the patient will express relief of
painful symptoms and verbalize a
decrease in severity of pain.
INTERVENTIONS

MONITOR VITAL
SIGNS

RATIONALE:
Alterations from normal maybe
signs of infection.
INTERVENTIONS

ELEVATE THE HEAD OF THE BED AND


POSITION THE PATIENT IN SEMI
FOWLER’S.

RATIONALE:
To increase oxygen level by
allowing optimal lung expansion.
INTERVENTIONS

PLACE THE PATIENT IN COMPLETE


BED REST DURING SEVERE EPISODES
OF PAIN.

RATIONALE:
To reduce gastrointestinal
stimulations thereby decreasing GI
activity.
INTERVENTIONS

PERFORM NON-PHARMACOLOGICAL
RELIEF METHODS: TECHNIQUES SUCH
AS
DEEP BREATHING GUIDED PROVISION OF
EXERCISES IMAGERY DESTRUCTION SUCH AS TV
AND RADIO

RATIONALE:
To provide optimal comfort to the
patient.
INTERVENTIONS

ADMINISTER PRESCRIBED PAIN


MEDICATIONS

RATIONALE:
To alleviate pain
INTERVENTIONS

ADMINISTER PRESCRIBED PAIN


MEDICATIONS

RATIONALE:
To alleviate pain
EVALUATION
RE PLAN
NURSE Hirap akong
STATION dumumi

ASSESSMENT
OBJECTIVE:
• Constipation
NURSE alternating with
diarrhea
STATION
SUBJECTIVE: • Bloated
“Hirap po akong • RLQ: Diminished
dumumi” as bowel sounds
verbalized by the • Stool: Having
difficulty moving
patient.
bowel but has bouts
frequent soft stools
• Vital signs:
-BP: 132/80 mmHg
-PR:92 bpm
-Temp.: 37.5℃

ASSESSMENT
DIAGNOSIS:
Constipation related to Change in
Normal Bowel Habits as evidenced by
Bloating of the Abdomen
PLANNING:
Within 8 hours of nursing
intervention, the client will establish
or return to normal patterns of bowel
functioning.
INTERVENTIONS

DETERMINE STOOL COLOR, CONSISTENCY,


FREQUENCY AND AMOUNT.

RATIONALE:
Assists in identifying causative or contributing
factors and appropriate interventions
INTERVENTIONS

AUSCULTATE BOWEL SOUNDS

RATIONALE:
Bowels sounds are generally
decreased in constipation.
INTERVENTIONS

ENCOURAGE INCREASED FLUID INTAKE


OF 2500 – 3000 ML/DAY WITHIN CARDIAC
TOLERANCE.

RATIONALE:
Sufficient fluid intake is necessary for the bowel to absorb
sufficient
amounts of liquid to promote proper stool consistency.
INTERVENTIONS

RECOMMEND AVOIDING GAS-FORMING FOODS


SUCH AS NUTS, PEAS AND SPICY FOODS

RATIONALE:
Decrease gastric distress and
abdominal distension.
INTERVENTIONS

INSTRUCT CLIENT ON A HIGH-FIBER


DIET, AS APPROPRIATE.

RATIONALE:
Fiber absorbs water, which adds bulk and
softness to the stool and speeds up passage
through the intestines.
functioning.

EVALUATION

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