NURSING DIAGNOSIS  Acute pain related to inflammation, edema, distention of the pancreas, and peritoneal irritation  Ineffective breathing

pattern related to severe pain, pulmonary infiltrates, pleural effusion, atelectasis, and elevated diaphragm  Imbalanced nutrition, less than body requirements, related to reduced food intake and increased metabolic demands  Impaired skin integrity related to poor nutritional status, bed rest, multiple drains, and surgical wound GOALS  Relief of pain and discomfort  Improved respiratory function  Improved nutritional status  Maintenance of skin integrity  Prevent complications NURSING CARE PLAN Nursing Diagnosis -Acute pain related to inflammation Analysis -Because the pathologic process Goal and Objectives Goal: By December 18, 2008, the Nursing Interventio ns Rationale Evaluation The client reports relief of pain and

, edema, distention of the pancreas, and peritoneal irritation

responsible for pain is autoindigestio n of the pancreas the objective is to relieve pain and decrease pancreatic enzymes.

client will report relief of pain and discomfort.

discomfort. -Uses analgesics and anticholinergic s as prescribed Objectives: without After all the -with held -decrease overuse. nursing oral feedings the -Maintains interventions formation of bedrest as , the client secretin prescribed will be able -the patient -Avoids to report is maintained -to restore alcohol to relief of pain on parenteral and maintain decrease from pain fluids and fluid balance abdominal scale of 9 to electrolytes pain. 6. -Nasogastric suction -to relieve n/v or to treat abdominal distention and paralytic -frequent oral ileus hygiene and care -to decrease

discomfort from the nasogastric tube and to relieve dryness of -Maintain bed the mouth rest -to decrease the metabolic reate and reduce the secretion of pancreatic and gastric -If enzymes experiencing severe pain, -the client report to may be physician experiencing hemorrhage of the pancreas or the dose of the

-provide frequent and repeated but simple explanations about the need for withholding fluids, maintenance of gastric suction, and bed rest.

analgesics may be inadequate -The patient often has clouded sensorium because of severe pain, fluid & electrolyte disturbances, and hypoxia.

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