Cholecystectomy Nursing Care Plan: Post-Operative Acute Pain

Assessment S: patient may verbalize: > unrelieved pain O: patient may manifest: > (+) facial grimaces >appears irritable, restlessness >guarded or protective behavior >diaphoresis >inability to sleep Nursing Diagnosis Acute pain Scientific Explanation In performing cholecystectomy, surgical incision is done. By which, the incision causes direct irritation to the nerve endings by chemical mediators released at the site such as bradykinin. This irritation will send signal to the cortex and thalamus of the brain thus producing pain perception. Planning (Objective/Goal) Short-term: After 2 hours of nursing interventions, the patient will report relief from pain. Interventions 1. administer medication as ordered 2. Monitor and record vital signs 3. assess the severity, frequency, and characteristic of pain Rationale 1. to minimize the pain Evaluation Short-term: After 2 hours of nursing interventions. the patient shall have reported relief from pain. Long-term: After 4 hours of nursing interventions, the patient shall have reported pain is controlled.

2. for baseline data

Long-term: After 4 hours of nursing interventions, the patient report pain is controlled.

4. provide divertional activities such as reading newspapers 5. provide nonpharmacologial intervention such as touch and frequent changing of position

3. pain is a subjective data, therefore it should be reported and to determine patients level of pain 4. to divert the pain the patient is experiencing

5. to provide comfort