Risk for imbalanced nutrition less than body requirement R/T: impaired fat suggestion due to obstruction of bile flow Nursing diagnosis Patient outcomes LET goals/SST Objectives Nursing Plan/lamentations Rationale Evaluation Nursing Diagnosis: Acute pain RITE: inflammation and obstruction of the gallbladder ABE: patient verbalizes abdominal pain of 7/10, grimaces, rubs his stomach, BP 158/79, TIFF Objective: T:OFF oral, BEBOP/79, ROR breaths/min, PAP beats/min , pain 4/10 on a scale of 0-10, grimaces, rubbing stomach, fever, low BUN, Subjective: I have a continuous, aching, and cramping pain in my stomach.
Patient said that he seed to weight bass and he lost more than bass LET Goal: Patient will describe non-pharmacological methods that can be used to relieve pain by the end of this 8 hours shift SST Goals: 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.
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Treatments: 4. Promote bed-rest, allowing patient to assume position of comfort. Medications to achieve goal: 5. Administer MGM of acetaminophen every ours as prescribe by the physician. 6. Administer leg of cooperation daily. Anticipate and how to prevent / Prevent palatal stimuli Day positioning patient In anatomical alignment according to his preference. Teach: 8. Teach and implement non-pharmacological interventions such as relaxation and guided imagery, and deep-breathing exercises when pain is relatively well-controlled tit pharmacological interventions. . Helps evaluate degree of effectiveness and discomfort. (Ackley & Ludwig, 2011) 2. This comfort pain level will provide the basis to determine effectiveness of pain management interventions. (Ackley & Ludwig, 2011) 3. Unrelieved acute pain can have physiological and psychological consequences that facilitate negative client outcomes. (Ackley & Ludwig, 2011) 4. This reduces muscle tension or spasm and to redistribute pressure on body parts. (Ralph & Taylor, 2014) 5. This will help minimize or relieve the pain.