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    NCP Cholangitis

    Uploaded by

    Janica C. Bayaua
    This nursing care plan addresses a patient experiencing abdominal pain likely due to cholangitis. The plan includes 7 goals and objectives to assess and manage the patient's pain over a 3 hour period through interventions such as pain assessment, monitoring relaxation techniques, positioning, and administering analgesics. The goals are to reduce the patient's pain, discomfort, and anxiety and have them verbalize willingness to alleviate pain.

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    © All Rights Reserved
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    NCP Cholangitis

    Uploaded by

    Janica C. Bayaua
    6K views4 pages
    This nursing care plan addresses a patient experiencing abdominal pain likely due to cholangitis. The plan includes 7 goals and objectives to assess and manage the patient's pain over a 3 hour period through interventions such as pain assessment, monitoring relaxation techniques, positioning, and administering analgesics. The goals are to reduce the patient's pain, discomfort, and anxiety and have them verbalize willingness to alleviate pain.

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    © © All Rights Reserved

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    This nursing care plan addresses a patient experiencing abdominal pain likely due to cholangitis. The plan includes 7 goals and objectives to assess and manage the patient's pain over a 3 hour period through interventions such as pain assessment, monitoring relaxation techniques, positioning, and administering analgesics. The goals are to reduce the patient's pain, discomfort, and anxiety and have them verbalize willingness to alleviate pain.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    6K views4 pages

    NCP Cholangitis

    Uploaded by

    Janica C. Bayaua
    This nursing care plan addresses a patient experiencing abdominal pain likely due to cholangitis. The plan includes 7 goals and objectives to assess and manage the patient's pain over a 3 hour period through interventions such as pain assessment, monitoring relaxation techniques, positioning, and administering analgesics. The goals are to reduce the patient's pain, discomfort, and anxiety and have them verbalize willingness to alleviate pain.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 4
    At a glance
    Powered by AI
    The key takeaways are that the patient is experiencing abdominal pain likely due to cholangitis. The nursing care plan aims to manage the patient's pain and discomfort.

    The goal is for the patient to be free from pain in the abdomen within 3 hours. The objectives include assessing pain characteristics and factors, assessing for fear/anxiety, identifying causes of discomfort, monitoring pain levels, and assessing willingness to alleviate pain.

    Interventions to manage pain include assessing pain, monitoring for discomfort, encouraging relaxation techniques like deep breathing, administering analgesics as prescribed, and noting the patient's response to pain medications.

    NURSING CARE PLAN

    CUES
    NURSING
    DIAGNOSIS
    ANALYSIS GOAL & OBJECTIVES INTERVENTION RATIONALE EVALUATION

    Subjective:
    The patient
    verbalized:
    Masakit tiyan
    ko

    Objective
    Observed
    evidence of
    pain
    Guarding
    behavior
    Frequently
    changing
    position to
    avoid pain
    Irritability
    Facial grimace


    Acute pain
    related to
    spasms and
    abdominal
    pain.

    Cholangitis
    is the most
    serious
    complicatio
    n of
    gallstones
    and more
    difficult to
    diagnose. It
    is caused
    by
    impacted
    stone in
    the
    common
    bowel
    duct,
    resulting in
    bile stasis,
    bacteremia
    and
    septicemia
    if left
    untreated.
    It is more
    ikely to
    occur when
    an already
    infected

    Goal: After 3 hours of nursing
    interventions the client will be
    free from experiencing pain in
    the abdomen.

    Objectives:

    1. After 40 minutes
    of assessment, the
    client will be able
    to describe the
    characteristic,
    onset, location,
    duration, severity,
    and precipitating
    factors of pain.






    2. After 15 minutes
    of assessing for
    the presence of
    fear or anxiety,
    the client will be
    able to verbalize if
    shes feeling








    >Assess the client of
    pain to include the
    characteristic, onset,
    location, duration,
    severity, and
    precipitating factors
    of pain.








    >Assess for the
    presence of fear or
    anxiety.












    >Pain is a subjective
    experience and must
    be described by the
    patient in order to
    plan effective
    treatment.

    (http://wps.prenhall.
    com/wps/media/obje
    cts/3918/4012970/N
    ursingTools/ch46_NC
    P_AcutePain)



    >Fear and anxiety
    can alleviate clients
    perception of pain.

    (http://bja.oxfordjour
    nals.org/content/87/
    1/144.full)

    __Met
    __Partially met
    __Unmet
    bile duct
    becomes
    obstructed.
    Patients
    having
    cholangitis
    is suffering
    from
    severe
    abdominal
    pain.

    (All-in-one
    Care
    Planning
    Resource
    by
    Swearinge
    n; page
    453)
    anxious.


    3. After 15 minutes
    of assessing for
    clients
    discomfort, client
    will verbalize the
    cause of
    discomort.











    4. After 10 minutes
    of monitoring the
    patient for pain,
    the client will be
    able to verbalize
    the rate of pain
    she is
    experiencing.



    5. After 30 minutes
    of deep breathing



    >Assess causes of
    possible discomfort.
















    >Monitor patient for
    pain or other
    discomfort. Devise a
    pain scale with
    patient, rating
    discomfort on a scale
    of 0 (no pain) to 10
    (worst pain)



    > Encourage use of
    relaxation techniques



    > Discomfort can be
    caused or aggravated
    by presence of
    nonpatent indwelling
    catheters causing
    bladder pain, NG
    tube resulting in
    gastric fluid and gas
    accumulation, or
    parenteral lines that
    have infiltrated IV
    fluids or medications.

    (Nursing Care Plans
    by Doenges, 8
    th
    ed;
    page 798)


    >Enables more
    precise measurement
    of discomfort and
    relief obtained.

    (All-in-one Care
    Planning Resource by
    Swearingen; page
    454)


    > Relieves muscle
    and emotional
    exercise and doing
    the bent-knee
    position, the client
    will be able to
    verbalize that the
    abdominal tension
    will be
    relieved/reduced.










    6. 30 minutes after
    administering
    analgesics, client
    will report
    reduced
    abdominal pain.










    such as deep-
    breathing exercises.




    >Position the client in
    a bent-knee position.










    >Administer
    analgesics as
    prescribed.













    tension; enhances
    sense of control and
    may improve coping
    abilities.


    >This position
    decreases tension on
    abdominal contents
    to promote comfort.

    (All-in-one Care
    Planning Resource by
    Swearingen; page
    454)



    >Nonsteroidal
    antiinflammantory
    drugs (NSAIDs) or
    opioid analgesics
    may be indicated,
    depending on
    severity of the pain.
    For the postoperative
    patient, continuous
    IV of opioid
    analgesics are used
    with increasing
    frequency and
    efficacy.

    (All-in-one Care





    7. After 40 minutes
    of nursing
    interventions the
    client will be able
    to verbalize
    willingness to
    alleviate pain.









    > Note clients
    attitude towards pain
    and use of pain
    medications.

    > Evaluate clients
    response to
    analgesics and assist
    in transitioning or
    altering drug
    regimen, based on
    individual needs and
    protocols.


    Planning Resource by
    Swearingen; page
    455)


    >To promote
    wellness

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