1. Acute pain R/T: inflammation and obstruction of the gallbladder AEB: patient verbalizes abdominal pain of 7/10, grimaces, rubs his stomach, BP 158/79, T990F 2. Deficient knowledge R/T: lack of knowledge about the importance of incentive spirometer AEB: patient says that he does not know how to use and needs to know more about its importance. 3. Risk for deficient fluid volume R/T: restricted intake
4. Risk for imbalanced nutrition less than body requirement R/T: impaired fat digestion due to obstruction of bile flow
LT goals/ST Objectives
Acute pain R/T: inflammation and obstruction of the gallbladder AEB: patient verbalizes abdominal pain of 7/10, grimaces, rubs his stomach, BP 158/79, T990F
T:99F oral, BP158/79, R18 breaths/min, P70 beats/min , pain 4/10 on a scale of 0-10, grimaces, rubbing stomach, fever, low BUN,
I have a continuous, aching, and cramping pain in my stomach. Patient said that he used to weight 250lbs and he lost more than 60lbs LT Goal:
Patient will describe non-pharmacological methods that can be used to relieve pain by the end of this 8 hours shift
By 9 AM of this 8 hours shift, Patient will report a pain relieve of 0/10 on a scale of 0-10 Assess & Monitor.
1. Assess pain location, intensity by using a numerical pain rating scale, and characteristic every 2 hours. 2. Ask the client to identify a comfort pain level on a scale of 0-10 that will allow him to perform desired activities easily.
Report if ……
3. Report to physician if pain is not being relieved.
4. Promote bed-rest, allowing patient to assume position of comfort.
Medications to achieve goal:
5. Administer 325mg of acetaminophen every 4hours as prescribe by the physician.
6. Administer 1g of...
References: Ackley, B. J., & Ladwig, G. B. (2011). Nursing Diaagnosis Handbook. St. Louis: Mosby.
Lewis, S. L., Dirksen, S., Heitkemper, M. M., Bucher, L., & Camera, I. M. (2011). Medical Surgical Nursing: Assesssment and Management of Clinical Problems. St. Louis: Elsevier.
Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of Nursing. St. Louis: Mosby.
Ralph, S. S., & Taylor, C. M. (2014). Nursing Diagnosis: Reference Manual. St. Louis: Mosby.
Please join StudyMode to read the full document